P C - A
PC-ACE PRO32
CLAIMS PROCESSING SYSTEM
USER'S MANUAL
Release 2.50
January, 2014
Copyright 1998-2014 MedLink Technologies, Inc.
All Rights Reserved
Table of Contents
Introducing PC-ACE Pro32
1
Getting started with PC-ACE Pro32
3
PC-ACE Pro32 Setup Procedures
7
Setup of Medicare Part A Systems
7
Setup of Institutional All-Payer Systems
14
Setup of Professional Systems
20
Main Toolbar & Forms 27
The PC-ACE Pro32 Main Toolbar
27
Institutional & Professional Claims Menus
28
Claim List Form Features
29
The Institutional Claim Form
35
The Professional Claim Form
43
Eligibility Benefit Request List Form Features
51
The Eligibility Benefit Request Form
57
The Service Type Eligibility Benefit Request Form
62
Roster Billing List Form Features
66
The Professional Roster Billing Form
68
Home Health Plan of Care List Form Features
71
The Home Health Plan of Care Form
73
Reference File Maintenance Form
76
Claim & Reference File Edit Validation
81
Security & User Maintenance
83
System Preferences
85
Preferences Overview
85
General Preferences
86
Claim List Preferences
90
Claim Import Preferences
91
Printing Preferences
92
Data Communication Preferences
97
Miscellaneous Preferences
98
Common Claim Activities
101
Adding a new claim
101
Listing, modifying and maintaining claims
102
Importing claims
104
Reversing the most recent claim import run
108
Processing claims automatically
109
Preparing claims for transmission
112
Transmitting electronic claim files
115
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Viewing and maintaining transmission acknowledgment files
117
Reactivating previously transmitted claims
119
Preparing claim status request files for transmission
121
Viewing and maintaining claim status response and acknowledgment files
123
Viewing and maintaining the claim status request/response history
126
Printing claims
128
Posting claim payments (Institutional)
131
Posting claim payments (Professional)
133
Archiving and unarchiving claims
135
Adding a new eligibility benefit request
138
Listing, modifying and maintaining eligibility benefit requests
140
Preparing eligibility benefit request files for transmission
142
Viewing and maintaining eligibility benefit response files
145
Viewing the eligibility benefit response for a specific request
147
Adding a new roster billing
149
Listing, modifying and maintaining roster billings
150
Adding a new Home Health Plan of Care
152
Listing, modifying and maintaining Plans of Care
153
Printing Home Health Plans of Care
155
Common Reference File Procedures
157
Adding and maintaining patients
157
Adding and maintaining payers
160
Adding and maintaining providers (Institutional)
163
Adding and maintaining providers (Professional)
166
Maintaining Codes & Miscellaneous Reference Files
169
Codes & Miscellaneous Reference Files Overview
169
Submitter File Maintenance
171
Data Communications File Maintenance
177
HCPCS Codes File Maintenance
179
HCPCS Modifiers File Maintenance
180
ICD9 Codes File Maintenance
182
Physician (UPIN) File Maintenance
183
Type of Bill (TOB) File Maintenance
184
Condition/Occurrence/Span/Value Codes File Maintenance
185
Revenue Codes File Maintenance
186
Place of Service (POS) File Maintenance
189
Facility File Maintenance
190
Charges Master File Maintenance
191
Provider Specialty File Maintenance
193
Provider Taxonomy Codes File Maintenance
194
Claim Adjustment Reason Codes File Maintenance
195
Remittance Remark Codes File Maintenance
196
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Eligibility Request Service Type Codes File Maintenance
197
Claim Status Response Codes File Maintenance
198
Miscellaneous Functions
199
Adding or modifying a system user
199
Scheduling unattended claim activities
200
Launching the ANSI-835 Electronic Remittance Module
203
Performing system backups/restores
204
Packing and reindexing the databases
207
Sending support mail to your distributor
209
Troubleshooting211
Reviewing the claim activity logs
211
Recovering from an interrupted claim prepare run
212
Index
214
iii
Introducing PC-ACE Pro32
Welcome to MedLink Technologies' PC-ACE Pro32 Claims Processing System - the system
of choice for electronic healthcare claims submission and management. PC-ACE Pro32 is a
complete, self-contained electronic claims processing system. It can be used in a stand-alone
configuration or in conjunction with your existing claims management system. Designed
exclusively for Microsoft Windows, PC-ACE Pro32 is the latest generation of MedLink
Technologies' electronic claims processing systems that have been successfully serving the
healthcare community for over ten years.
Key Features
PC-ACE Pro32 is a comprehensive claims management system. Some of the more prominent
features include:
Combined Medicare Part A, Institutional All-Payer and Professional claims system
Electronic submission of claims in ANSI-837 format
Flexible claim import from existing systems
Remittance translation/export to existing systems
Comprehensive real-time claims editing minimizes rejected claims
Field-level edit validation provides immediate user feedback
Automatic code validation (diagnosis, procedure, etc.)
Detailed claim import & edit validation error reporting
Context-sensitive pop-up selection lists speed claim entry and promote accuracy
Prints Institutional and Professional claims on plain paper or pre-printed forms
Maintains claim payment history
Unattended scheduling of claims activities
Integrated backup, restore and file maintenance functions
Familiar Microsoft Windows "look and feel"
Comprehensive on-line help system
Technical support through direct customer service line and Internet web site
Ongoing maintenance, updates and enhancements
Thank you for choosing PC-ACE Pro32 as the electronic claims processing system for your
facility or organization. It is our commitment to provide you with a quality product and
outstanding support. We will strive to constantly improve and enhance PC-ACE Pro32 to serve
st
the ever-changing needs of the healthcare community well into the 21 century.
1
Getting started with PC-ACE Pro32
The PC-ACE Pro32 Claims Processing System was designed from the ground up for the
Windows environment. Special care has been taken to ensure that PC-ACE Pro32 looks and
feels like other popular Windows programs. This means that you can concentrate on PC-ACE
Pro32's features rather than worrying about how to navigate the program.
This section describes the recommended minimum system requirements for PC-ACE Pro32.
Follow the steps to install the PC-ACE Pro32 server and client (optional) modules. The final
paragraph of this "Getting Started" section will direct you to the relevant setup tasks required to
get you operational with PC-ACE Pro32.
Minimum System Requirements:
SVGA monitor resolution (800 x 600)
Windows 8, Windows 7, Vista or XP operating system
Adobe Acrobat Reader Version 4.0 or later (for overlaid claim printing)
Note: When the Windows "Large Fonts" display setting is enabled, the screen resolution must
be 1024 x 768 or higher. The Institutional Claim Form and Professional Claim Form will not
display properly at lower screen resolutions.
PC-ACE Pro32 Server Installation:
Perform these steps to install the PC-ACE Pro32 server (or single-user install):
1) If you are downloading PC-ACE Pro32, save the installation program (SETUP.EXE) to a
temporary folder on your computer (for example, the Windows desktop). Double-click the
SETUP.EXE icon to begin the PC-ACE Pro32 installation process.
For compact disk media, the installation program should execute automatically when you
insert the disk into your CDROM drive. If the Windows auto-detect feature is disabled, you
may need to start the installation program manually. To do so, type "D:\setup" in the "Run"
dialog (accessible from the Windows Start menu), substituting the drive letter of your
CDROM drive for the "D" in this example.
2) Follow the on-screen wizard steps to complete the server installation. You will be prompted
to select a destination drive. For best performance, select a drive local to your machine. If
multi-user operation is required, select a drive accessible by all workstations on the network
that will require PC-ACE Pro32 access. The PC-ACE Pro32 files will be installed to the
WINPCACE directory on the selected drive. Desktop icons will be created for PC-ACE
Pro32 and the current README file.
Note: If you performed this server installation to a remote hard drive, you can improve
program execution speed on this workstation by also performing the client installation below.
This will install a copy of the PC-ACE Pro32 main program and support files to your local hard
drive. If you performed the server installation to a local hard drive, you should skip the client
installation for this workstation. You will still be required to perform the client installation for
any additional workstations that require PC-ACE Pro32 access.
PC-ACE Pro32 Client Installation:
If multi-user operation is required, perform this client installation procedure from each
workstation that requires PC-ACE Pro32 access. Perform these steps to install the PC-ACE
Pro32 client:
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PC-ACE Pro32 User's Manual
1) Confirm that the workstation has network access (via a mapped drive letter) to the hard
drive volume containing the PC-ACE Pro32 server installation directory (WINPCACE). You
must have access to this remote drive volume before proceeding with the PC-ACE Pro32
client installation.
2) Using the Windows Explorer, locate the client installation program (CLIENT32.EXE) in the
WINPCACE directory on the server. Execute this program directly from the remote drive
volume (do not copy CLIENT32.EXE to your local system).
3) Follow the on-screen wizard steps to complete the client installation. You will be prompted
to select a local destination drive. The PC-ACE Pro32 program and client support files will
be installed to the WINPCACE directory on the selected local drive. In addition, a PC-ACE
Pro32 shortcut icon will be created and placed on your Windows desktop
Logging In The First Time
Users are required to log into PC-ACE Pro32 before performing any system activities. The
login process involves entering a User ID and optional Password. As shipped, PC-ACE Pro32
is configured with a single default user with full system access rights. The default user's User
ID is "SYSADMIN" and password is "SYSADMIN" as well. If you are logging into PC-ACE
Pro32 for the first time, use this default login (unless instructed otherwise by your distributor). If
the default login does not work, review the installation guidelines provided by your distributor.
Distributors often pre-configure the security system according to their own internal
specifications. If you still have difficulties logging into the system, contact your distributor for
assistance. IMPORTANT: You should change the default user's password as soon as possible
if you are concerned about controlling user access at your facility.
How To Use This Help System
This on-line help system provides instant access to helpful information from anywhere in the
PC-ACE Pro32 system. Features of the on-line help system include:
Context-Sensitive Access - Just press the "F1" key from anywhere in PC-ACE Pro32 to
display help information relevant to your current location in the program. For example,
hitting "F1" while entering an Institutional claim will display the "Institutional Claim Form"
topic.
Help System Contents - The "Contents" tab of the PC-ACE Pro32 help system presents
all help topics in a nested "table of contents" format. Just double-click on a topic entry to
display the topic, or double-click on a folder entry to reveal the next level of topics and
folders.
Help System Index - The "Index" tab of the PC-ACE Pro32 help system lists all available
index entries and allows the user to easily jump to the first index entry that matches a
user-entered search string. Just double-click on an index entry to display the
corresponding topic.
Help System Search - The "Search" tab (labeled "Find" on older Help systems) of the
PC-ACE Pro32 help system permits the user to perform a free-form text search of all
topics in the entire help system. Simply enter the search word or phrase and the topics
that include this search string will be automatically listed. Again, just double-click an entry
in the search results list to open the corresponding topic.
Within the various help topic windows, you will encounter several informational icons
positioned in the left margin. These are used to convey additional information that may be of
special interest.
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Getting started with PC-ACE Pro32
Tip: This informational icon is used to pass along tips that improve the usability of the
application.
Note: This informational icon is used to present special notes relating to the current
help topic. These may indicate a requirement or restriction of the application. In some
cases, they are simply general interest items.
Attention: This informational icon is used to bring attention to an important issue
relating to the current topic. Often these instructions must be taken to ensure optimum
operation of an application feature.
Where Do I Go From Here?
You will need to perform a few setup tasks before using PC-ACE Pro32 to process claims.
Proceed to the appropriate setup section below based on the type of claims you will be
processing.
Medicare Part A clients proceed to the Setup of Medicare Part A Systems section.
Institutional All-Payer clients proceed to the Setup of Institutional All-Payer Systems
section.
Professional clients proceed to the Setup of Professional Systems section.
These sections present detailed instructions on how to set-up your PC-ACE Pro32 system.
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PC-ACE Pro32 Setup Procedures
Setup of Medicare Part A Systems
This section describes the setup procedures required to prepare your PC-ACE Pro32 system
for Medicare Part A Only claims processing. Topics to be covered include setting up the
Payer, Provider, and Patient (optional) reference files. A section on claim import considerations
is included for users who will be importing claims from an upstream claims management
system. Finally, a section covering considerations for claims preparation and transmission
should be reviewed.
Attention: Your distributor may have already completed some of the setup steps
described in this section. Supplement this setup topic with any installation notes
provided by your distributor. If you are in doubt about exactly which steps you need to
perform, contact your distributor for assistance.
Tip: You may want to print this help topic and refer to the printed version as you perform
these setup steps. You can check off the steps as they are completed. This technique
also frees you to jump around between on-line help topics without losing your place in
the setup procedure. To print the topic, just click the "Print" button at the top of this online Help screen.
Payer Reference File Setup
This section describes the process of setting up the Payer reference file. This file contains
information about the valid payers in your system. All payers to be specified on your Medicare
Part A claims must exist in the Payer reference file (with the exception of a special "dump"
payer). Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining payers" topic for more
information on entering Payer records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Payer" tab to display a list of all
existing Payer records.
Attention: One or more Payer records may already exist in the system if your
distributor has already setup this reference file for you. Consult the distributor's
installation notes or contact your distributor for assistance before continuing this
Payer setup procedure.
2) Click the "New" button to display the Payer Information form. Enter the new payer’s
information, taking advantage of the built-in lookups where possible (by pressing the "F2"
key or right-clicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The "Payer ID", "LOB", and "Usage" fields together serve as the identification "key" for
this Payer record. A specific "Payer ID / LOB" combination may exist for a maximum of
two Payer records. If two such Payer records are defined, then their "Usage" settings must
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PC-ACE Pro32 User's Manual
not overlap. Valid "Usage" settings include "U" (Institutional use only), "H" (Professional
use only), and "B" or blank (unrestricted use). The only valid situation where two Payer
records with the same "Payer ID / LOB" combination may exist is when one of the records
specifies a "Usage" value of "U" (Institutional use only) and the other record specifies a
"Usage" value of "H" (Professional use only). This feature permits Payers for shared LOBs
such as Commercial (COM) to optionally have distinct settings and PrintLink matching
strings for Institutional versus Professional use.
An individual Payer record must be setup for each line-of-business (LOB) handled by that
payer. For example, if payer "12345" will receive both Medicare and Medicaid claims, then
two Payer records must be added - both with Payer ID = "12345", one with LOB = "MCA",
and the other with LOB = "MCD".
Note: Since this is a Medicare Part A Only system, it is conceivable that you will
only be required to setup one Payer record. This record would contain the Payer ID
of your Medicare Part A payer and an LOB of "MCA". You may decide to add
additional Payer records for other lines of business if you want to include these on
the claim's secondary and tertiary payer lines.
3) Click the "Save" button to save the new Payer record. An edit validation process will be
performed to check for problems with the payer information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Payer record
should now be visible in the Payer list.
Note: If you plan on using the PrintLink feature of PC-ACE Pro32 to import claims
from "print image" files, then you will also need to add PrintLink Matching
Description strings to this Payer record. The "Claim Import Considerations" section
later in this topic will lead you through this process.
4) Repeat the relevant steps to create additional Payer records as needed. This may include
records for the same payer (and different LOBs) or records for additional payers.
5) When all desired Payer records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
Provider Reference File Setup
This section describes the process of setting up the Institutional Provider reference file. This
file contains information about the valid providers in your system. All providers for whom you
will be billing Medicare Part A claims must exist in the Institutional Provider reference file. The
Institutional Provider reference file is organized such that each record describes a valid
provider for a single line of business (LOB). This organization allows for greater flexibility in
specifying Provider IDs and support information (Tax ID, address, etc) that can vary across
multiple LOBs for a single provider. Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining providers (Institutional)" topic
for more information on entering Institutional Provider records. If you do, make sure and
return to this topic to continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Provider" tab to display a list of
all existing Provider records.
2) If you have just installed PC-ACE Pro32, the Provider list should be empty. If so, skip to the
next step.
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PC-ACE Pro32 Setup Procedures
Attention: Some distributors include sample provider records for illustration
purposes. You can choose to either modify these existing records to add any
missing information, or delete them and build your Provider reference file from
scratch.
If the list is not empty, consult your distributor's installation instructions or contact the
distributor to confirm that the existing Provider records can be safely deleted. To delete a
Provider record, select the desired record in the list and click the "Delete" button. Click the
"OK" button on the Provider Deletion Confirmation form to confirm the deletion request.
Make sure the list is empty before continuing with the next step.
3) Click the "New" button to display the Institutional Provider Information form. Enter the first
provider's information, taking advantage of the built-in lookups where possible (by pressing
the "F2" key or right-clicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
4) Enter the provider's name and address information. Enter the Provider ID in the "Provider
ID/No." field and the line of business in the "LOB" field (probably "MCA"). The "Payer ID"
field is only needed if you want to restrict assignment of this provider to a specific payer.
Normally, the "Payer ID" field will be left blank. You can also leave the "Tag" field blank.
Complete entry of the remaining provider fields as desired.
5) Click the "Save" button to save the new Provider record. An edit validation process will be
performed to check for problems with the provider information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Provider record
should now be visible in the Provider list.
6) Repeat the last few steps to add each additional Provider record. Now each time you click
the "New" button, you will be prompted to select whether you want a completely new
provider (all fields blank to start with), or whether you would like to inherit the name/address
information from the currently selected provider. If you choose the "inherit" option, you will
also have the option to "associate" the new provider record with the selected provider
record. Provider records should be "associated" when they represent the same entity. For
example, if a provider supports multiple lines of business, one provider record for each LOB
should be created, and these related provider records should be "associated" with each
other. The "inherit" and "associate" options can be a real timesaver when setting up
providers that support multiple lines of business. In this scenario, select an existing provider
in the list, click the "New" button, and choose the "inherit" and "associate" options. You will
see that the top portion of the Provider Information form will be completed automatically.
Simply tab through or overwrite the "Provider ID/No." field (may be the same or different),
enter a unique line of business identifier in the "LOB" field, and click the "Save" button.
7) When you have finished adding Provider records, you should have one record for each
applicable line of business (LOB) for each provider entity. When all desired Provider
records have been added, click the "Close" button on the Reference File Maintenance form
to return to the PC-ACE Pro32 Main Toolbar.
Patient Reference File Setup
This section describes the process of setting up the Patient reference file. Setup of the Patient
reference file is optional. If you choose to setup patients, the complete patient list will be
accessible during claim entry using the variable-list lookup feature. When a patient is selected
from the lookup list during claim entry, all applicable patient information will be automatically
loaded into the appropriate claim form fields. Complete the following steps as needed:
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PC-ACE Pro32 User's Manual
Tip: You may want to refer to the "Adding and maintaining patients" topic for more
information on entering Patient records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Patient" tab to display a list of all
existing Patient records.
2) If you have just installed PC-ACE Pro32, the Patient list should be empty. If so, skip to the
next step. If the list is not empty, any existing Patient records are likely there as samples
only. Once you have confirmed that this is the case, delete all sample Patient records. To
delete a Patient record, select the desired record in the list, click the "Delete" button, and
confirm the deletion.
3) Click the "New" button to display the Patient Information form. Enter the patient information,
taking advantage of the built-in lookups where possible (by pressing the "F2" key or rightclicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The Patient reference file contains general patient information as well as optional primary,
secondary, and tertiary insured details. Enter as much information as you have available
for the patient.
4) Click the "Save" button to save the new Patient record. An edit validation process will be
performed to check for problems with the patient information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Patient record
should now be visible in the Patient list.
5) Repeat the relevant steps to create additional Patient records as needed.
6) When all desired Patient records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
User Account Setup
PC-ACE Pro32 requires that a valid login and optional password be entered by anyone
desiring access to the system. The system administrator must set up a "user" account for each
person that will use PC-ACE Pro32. The user account specifies the user's login/password
values and defines which activities the user has permission to perform. As shipped, PC-ACE
Pro32 is configured with a single default user with full system access rights. The default user's
User ID is "SYSADMIN" and password is "SYSADMIN" as well. Complete the following steps
to add additional user accounts:
Tip: You may want to refer to the "Adding or modifying a system user" topic for more
information on adding and maintaining users. If you do, make sure and return to this
topic to continue the setup steps.
1) Select the main "Security" menu from the PC-ACE Pro32 Main Toolbar and choose the
"Add/Update User" item. The Security List form will display a list of all existing user
accounts.
2) To add a new user account, click the "New" button on the Security List form and assign the
user a User ID, Password and Name. Assign permissions to this user and click the "OK"
button to save the new user record.
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PC-ACE Pro32 Setup Procedures
Tip: Check the checkbox next to the permission to allow access to the activity. Click
the "Check All" and "Clear All" buttons to quickly check or un-check all user
permission checkboxes.
3) Repeat the previous step to create additional user accounts.
Note: If changes are made to a user profile, the changes will not go into effect until the
next time that user logs into system. Select the "Logout Current User" item on the
main "Security" menu to manually log out without exiting the system.
Attention: You should change the default user's password as soon as possible if
you are concerned about controlling user access at your facility.
Claim Import Considerations
This section describes setup considerations that should be reviewed only if you intend to
import claims into PC-ACE Pro32 from an upstream system. If you will not be importing claims,
skip this section entirely. Three methods are available for importing claims - Print Image
(PrintLink), Intermediate Delimited Format, and Electronic Media Claims (EMC) Format.
Note: Getting setup to import claims into PC-ACE Pro32 typically involves coordination
with your distributor. If you are interested in importing claims using the PrintLink print
image method, but your distributor does not provide PrintLink support, ask that they
refer you directly to the software manufacturer for assistance. PrintLink functionality
may be licensed and supported as an "add-on" to your base PC-ACE Pro32 system.
Tip: You may want to refer to the "Importing claims" topic for a discussion of these claim
import methods. If you do, make sure and return to this topic to continue the setup steps.
Review only the setup considerations applicable to the claim import method you intend to use.
Print Image (PrintLink) - imports claims from a print image file. If using this claim import
method, complete the following steps:
1) Have your distributor perform a one-time "PrintLink mapping" procedure on a
sample print image file that you have supplied. This mapping process defines the
template used to extract and interpret fields from your print image file. Since all
upstream systems print claims in a slightly different format, this mapping process is
required to build your custom template.
2) Obtain the resulting "map" file from your distributor. This file is typically named
"ub92.map", but can be any valid filename with a ".map" extension. The map file must
be placed in the server's "winpcace\impub92" directory.
3) Confirm the existence of the required "map control" file. This file provides a control
interface between the output of the PrintLink translator and the PC-ACE Pro32 claim
import routines. The map control file is always named "mapcntlu.win", and should be
located in the server's "winpcace\impub92" directory.
4) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the print file to
specific Payer reference file records. Refer to the "Adding and maintaining payers"
topic for details on setting up your PrintLink Matching Description strings.
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PC-ACE Pro32 User's Manual
Each time you want to import claims, copy the new print image file generated by your
upstream system into the server's "winpcace\impub92" directory. The first line of the
map file provided by your distributor dictates what the print image file must be named
(typically "ub92.prt").
Intermediate Delimited Format - imports claims from a file in "intermediate delimited"
format. If using this claim import method, complete the following steps:
1) Work with your distributor to develop the programs necessary to produce a file in
"intermediate delimited" format from your upstream system. Your distributor should
have detailed specifications of this internal file format. Verify that the generated files
meet these specifications.
2) Confirm the existence of the required "map control" file. This file provides a control
interface between the intermediate delimited file and the PC-ACE Pro32 claim import
routines. The map control file is always named "mapcntlu.win", and should be
located in the server's "winpcace\impub92" directory.
3) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the intermediate
delimited file to specific Payer reference file records. Refer to the "Adding and
maintaining payers" topic for details on setting up your PrintLink Matching Description
strings.
4) Each time you want to import claims, copy the new intermediate delimited file
generated by your upstream system into the server's "winpcace\impub92" directory.
The file must be named "plink.out".
Electronic Media Claims (EMC) Format - import claims from a file in Electronic Media
Claims (EMC) format. If using this claim import method, complete the following steps:
1) Confirm that your upstream system is capable of producing a supported version
Electronic Media Claims (EMC) format file. Contact your distributor for the list of
supported EMC file versions.
2) Each time you want to import claims, copy the new EMC file generated by your
upstream system into the server's "winpcace\impub92" directory. The file must have
a ".dat" file extension (e.g., "EMC192.DAT").
Claim Prepare & Transmit Considerations
This section describes setup considerations that should be reviewed before you attempt to
prepare and transmit claims using PC-ACE Pro32.
Note: Your distributor may have already performed some (or all) of this setup for you.
Consult your distributor's installation instructions or contact the distributor if it is unclear
how to proceed.
1) Setup default Institutional submitter information in the PC-ACE Pro32 Submitter reference
file. Information from this reference file is required during preparation of Electronic Media
Claims (EMC) files. Consult your distributor's installation instructions or contact the
distributor for assistance in setting up this critical reference file.
Tip: Refer to the "Submitter File Maintenance" topic for more information on setting
up the default Submitter record.
2) If required by your distributor, setup default Institutional data communications parameters
in the PC-ACE Pro32 Data Communications reference file. This reference file contains the
Institutional data communications parameters exported to the "bcdatcom.dat" file prior to the
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PC-ACE Pro32 Setup Procedures
launch of any external data communications program (e.g., file transmission). These
parameters are used by the third-party data communications program to control the file
transmission, etc.
Tip: Refer to the "Data Communications File Maintenance" topic for more information
on setting up the default Data Communications record.
This completes the required setup steps to ready PC-ACE Pro32 for Medicare Part A Only
claims processing.
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PC-ACE Pro32 User's Manual
Setup of Institutional All-Payer Systems
This section describes the setup procedures required to prepare your PC-ACE Pro32 system
for Institutional All-Payer claims processing. Topics to be covered include setting up the
Payer, Provider, and Patient (optional) reference files. A section on claim import considerations
is included for users who will be importing claims from an upstream claims management
system. Finally, a section covering considerations for claims preparation and transmission
should be reviewed.
Attention: Your distributor may have already completed some of the setup steps
described in this section. Supplement this setup topic with any installation notes
provided by your distributor. If you are in doubt about exactly which steps you need to
perform, contact your distributor for assistance.
Tip: You may want to print this help topic and refer to the printed version as you perform
these setup steps. You can check off the steps as they are completed. This technique
also frees you to jump around between on-line help topics without losing your place in
the setup procedure. To print the topic, just click the "Print" button at the top of this online Help screen.
Payer Reference File Setup
This section describes the process of setting up the Payer reference file. This file contains
information about the valid payers in your system. All payers to be specified on your
Institutional claims must exist in the Payer reference file (with the exception of a special
"dump" payer). Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining payers" topic for more
information on entering Payer records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Payer" tab to display a list of all
existing Payer records.
Attention: One or more Payer records may already exist in the system if your
distributor has already setup this reference file for you. Consult the distributor's
installation notes or contact your distributor for assistance before continuing this
Payer setup procedure.
2) Click the "New" button to display the Payer Information form. Enter the new payer’s
information, taking advantage of the built-in lookups where possible (by pressing the "F2"
key or right-clicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The "Payer ID", "LOB", and "Usage" fields together serve as the identification "key" for
this Payer record. A specific "Payer ID / LOB" combination may exist for a maximum of
two Payer records. If two such Payer records are defined, then their "Usage" settings must
not overlap. Valid "Usage" settings include "U" (Institutional use only), "H" (Professional
use only), and "B" or blank (unrestricted use). The only valid situation where two Payer
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PC-ACE Pro32 Setup Procedures
records with the same "Payer ID / LOB" combination may exist is when one of the records
specifies a "Usage" value of "U" (Institutional use only) and the other record specifies a
"Usage" value of "H" (Professional use only). This feature permits Payers for shared LOBs
such as Commercial (COM) to optionally have distinct settings and PrintLink matching
strings for Institutional versus Professional use.
An individual Payer record must be setup for each line-of-business (LOB) handled by that
payer. For example, if payer "12345" will receive both Medicare and Medicaid claims, then
two Payer records must be added - both with Payer ID = "12345", one with LOB = "MCA",
and the other with LOB = "MCD".
3) Click the "Save" button to save the new Payer record. An edit validation process will be
performed to check for problems with the payer information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Payer record
should now be visible in the Payer list.
Note: If you plan on using the PrintLink feature of PC-ACE Pro32 to import claims
from "print image" files, then you will also need to add PrintLink Matching
Description strings to this Payer record. The "Claim Import Considerations" section
later in this topic will lead you through this process.
4) Repeat the relevant steps to create additional Payer records as needed. This may include
records for the same payer (and different LOBs) or records for additional payers.
5) When all desired Payer records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
Provider Reference File Setup
This section describes the process of setting up the Institutional Provider reference file. This
file contains information about the valid providers in your system. All providers for whom you
will be billing Institutional claims must exist in the Institutional Provider reference file. The
Institutional Provider reference file is organized such that each record describes a valid
provider for a single line of business (LOB). This organization allows for greater flexibility in
specifying Provider IDs and support information (Tax ID, address, etc) that can vary across
multiple LOBs for a single provider. Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining providers (Institutional)" topic
for more information on entering Institutional Provider records. If you do, make sure and
return to this topic to continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Provider (Inst)" (or just
"Provider") tab to display a list of all existing Provider records.
2) If you have just installed PC-ACE Pro32, the Provider list should be empty. If so, skip to the
next step. If the list is not empty, contact your distributor to confirm that the existing Provider
records can be safely deleted. To delete a Provider record, select the desired record in the
list and click the "Delete" button. Click the "OK" button on the Provider Deletion
Confirmation form to confirm the deletion request. Make sure the list is empty before
continuing with the next step.
3) Click the "New" button to display the Institutional Provider Information form. Enter the first
provider's information, taking advantage of the built-in lookups where possible (by pressing
the "F2" key or right-clicking the mouse).
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PC-ACE Pro32 User's Manual
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
4) Enter the provider's name and address information. Enter the Provider ID in the "Provider
ID/No." field and the line of business in the "LOB" field. The "Payer ID" field is only needed
if you want to restrict assignment of this provider to a specific payer. Normally, the "Payer
ID" field will be left blank. You can also leave the "Tag" field blank. Complete entry of the
remaining provider fields as desired.
5) Click the "Save" button to save the new Provider record. An edit validation process will be
performed to check for problems with the provider information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Provider record
should now be visible in the Provider list.
6) Repeat the last few steps to add each additional Provider record. Now each time you click
the "New" button, you will be prompted to select whether you want a completely new
provider (all fields blank to start with), or whether you would like to inherit the name/address
information from the currently selected provider. If you choose the "inherit" option, you will
also have the option to "associate" the new provider record with the selected provider
record. Provider records should be "associated" when they represent the same entity. For
example, if a provider supports multiple lines of business, one provider record for each LOB
should be created, and these related provider records should be "associated" with each
other. The "inherit" and "associate" options can be a real timesaver when setting up
providers that support multiple lines of business. In this scenario, select an existing provider
in the list, click the "New" button, and choose the "inherit" and "associate" options. You will
see that the top portion of the Provider Information form will be completed automatically.
Simply tab through or overwrite the "Provider ID/No." field (may be the same or different),
enter a unique line of business identifier in the "LOB" field, and click the "Save" button.
7) When you have finished adding Provider records, you should have one record for each
applicable line of business (LOB) for each provider entity. When all desired Provider
records have been added, click the "Close" button on the Reference File Maintenance form
to return to the PC-ACE Pro32 Main Toolbar.
Patient Reference File Setup
This section describes the process of setting up the Patient reference file. Setup of the Patient
reference file is optional. If you choose to setup patients, the complete patient list will be
accessible during claim entry using the variable-list lookup feature. When a patient is selected
from the lookup list during claim entry, all applicable patient information will be automatically
loaded into the appropriate claim form fields. Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining patients" topic for more
information on entering Patient records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Patient" tab to display a list of all
existing Patient records.
2) If you have just installed PC-ACE Pro32, the Patient list should be empty. If so, skip to the
next step. If the list is not empty, any existing Patient records are likely there as samples
only. Once you have confirmed that this is the case, delete all sample Patient records. To
delete a Patient record, select the desired record in the list, click the "Delete" button, and
confirm the deletion.
16
PC-ACE Pro32 Setup Procedures
3) Click the "New" button to display the Patient Information form. Enter the patient information,
taking advantage of the built-in lookups where possible (by pressing the "F2" key or rightclicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The Patient reference file contains general patient information as well as optional primary,
secondary, and tertiary insured details. Enter as much information as you have available
for the patient.
4) Click the "Save" button to save the new Patient record. An edit validation process will be
performed to check for problems with the patient information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Patient record
should now be visible in the Patient list.
5) Repeat the relevant steps to create additional Patient records as needed.
6) When all desired Patient records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
User Account Setup
PC-ACE Pro32 requires that a valid login and optional password be entered by anyone
desiring access to the system. The system administrator must set up a "user" account for each
person that will use PC-ACE Pro32. The user account specifies the user's login/password
values and defines which activities the user has permission to perform. As shipped, PC-ACE
Pro32 is configured with a single default user with full system access rights. The default user's
User ID is "SYSADMIN" and password is "SYSADMIN" as well. Complete the following steps
to add additional user accounts:
Tip: You may want to refer to the "Adding or modifying a system user" topic for more
information on adding and maintaining users. If you do, make sure and return to this
topic to continue the setup steps.
1) Select the main "Security" menu from the PC-ACE Pro32 Main Toolbar and choose the
"Add/Update User" item. The Security List form will display a list of all existing user
accounts.
2) To add a new user account, click the "New" button on the Security List form and assign the
user a User ID, Password and Name. Assign permissions to this user and click the "OK"
button to save the new user record.
Tip: Check the checkbox next to the permission to allow access to the activity. Click
the "Check All" and "Clear All" buttons to quickly check or un-check all user
permission checkboxes.
3) Repeat the previous step to create additional user accounts.
Note: If changes are made to a user profile, the changes will not go into effect until the
next time that user logs into system. Select the "Logout Current User" item on the
main "Security" menu to manually log out without exiting the system.
Attention: You should change the default user's password as soon as possible if
you are concerned about controlling user access at your facility.
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PC-ACE Pro32 User's Manual
Claim Import Considerations
This section describes setup considerations that should be reviewed only if you intend to
import claims into PC-ACE Pro32 from an upstream system. If you will not be importing claims,
skip this section entirely. Three methods are available for importing claims - Print Image
(PrintLink), Intermediate Delimited Format, and Electronic Media Claims (EMC) Format.
Note: Getting setup to import claims into PC-ACE Pro32 typically involves coordination
with your distributor. If you are interested in importing claims using the PrintLink print
image method, but your distributor does not provide PrintLink support, ask that they
refer you directly to the software manufacturer for assistance. PrintLink functionality
may be licensed and supported as an "add-on" to your base PC-ACE Pro32 system.
Tip: You may want to refer to the "Importing claims" topic for a discussion of these claim
import methods. If you do, make sure and return to this topic to continue the setup steps.
Review only the setup considerations applicable to the claim import method you intend to use.
Print Image (PrintLink) - imports claims from a print image file. If using this claim import
method, complete the following steps:
1) Have your distributor perform a one-time "PrintLink mapping" procedure on a sample
print image file that you have supplied. This mapping process defines the template
used to extract and interpret fields from your print image file. Since all upstream
systems print claims in a slightly different format, this mapping process is required to
build your custom template.
2) Obtain the resulting "map" file from your distributor. This file is typically named
"ub92.map", but can be any valid filename with a ".map" extension. The map file must
be placed in the server's "winpcace\impub92" directory.
3) Confirm the existence of the required "map control" file. This file provides a control
interface between the output of the PrintLink translator and the PC-ACE Pro32 claim
import routines. The map control file is always named "mapcntlu.win", and should be
located in the server's "winpcace\impub92" directory.
4) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the print file to
specific Payer reference file records. Refer to the "Adding and maintaining payers"
topic for details on setting up your PrintLink Matching Description strings.
5) Each time you want to import claims, copy the new print image file generated by your
upstream system into the server's "winpcace\impub92" directory. The first line of the
map file provided by your distributor dictates what the print image file must be named
(typically "ub92.prt").
Intermediate Delimited Format - imports claims from a file in "intermediate delimited"
format. If using this claim import method, complete the following steps:
1) Work with your distributor to develop the programs necessary to produce a file in
"intermediate delimited" format from your upstream system. Your distributor should
have detailed specifications of this internal file format. Verify that the generated files
meet these specifications.
2) Confirm the existence of the required "map control" file. This file provides a control
interface between the intermediate delimited file and the PC-ACE Pro32 claim import
routines. The map control file is always named "mapcntlu.win", and should be
located in the server's "winpcace\impub92" directory.
18
PC-ACE Pro32 Setup Procedures
3) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the intermediate
delimited file to specific Payer reference file records. Refer to the "Adding and
maintaining payers" topic for details on setting up your PrintLink Matching Description
strings.
4) Each time you want to import claims, copy the new intermediate delimited file
generated by your upstream system into the server's "winpcace\impub92" directory.
The file must be named "plink.out".
Electronic Media Claims (EMC) Format - import claims from a file in Electronic Media
Claims (EMC) format. If using this claim import method, complete the following steps:
1) Confirm that your upstream system is capable of producing a supported version
Electronic Media Claims (EMC) format file. Contact your distributor for the list of
supported EMC file versions.
2) Each time you want to import claims, copy the new EMC file generated by your
upstream system into the server's "winpcace\impub92" directory. The file must have
a ".dat" file extension (e.g., "EMC192.DAT").
Claim Prepare & Transmit Considerations
This section describes setup considerations that should be reviewed before you attempt to
prepare and transmit claims using PC-ACE Pro32.
Note: Your distributor may have already performed some (or all) of this setup for you.
Consult your distributor's installation instructions or contact the distributor if it is unclear
how to proceed.
1) Setup default Institutional submitter information in the PC-ACE Pro32 Submitter reference
file. Information from this reference file is required during preparation of Electronic Media
Claims (EMC) files. Consult your distributor's installation instructions or contact the
distributor for assistance in setting up this critical reference file.
Tip: Refer to the "Submitter File Maintenance" topic for more information on setting
up the default Submitter record.
2) If required by your distributor, setup default Institutional data communications parameters
in the PC-ACE Pro32 Data Communications reference file. This reference file contains the
Institutional data communications parameters exported to the "bcdatcom.dat" file prior to the
launch of any external data communications program (e.g., file transmission). These
parameters are used by the third-party data communications program to control the file
transmission, etc.
Tip: Refer to the "Data Communications File Maintenance" topic for more information
on setting up the default Data Communications record.
This completes the required setup steps to ready PC-ACE Pro32 for Institutional All-Payer
claims processing.
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PC-ACE Pro32 User's Manual
Setup of Professional Systems
This section describes the setup procedures required to prepare your PC-ACE Pro32 system
for Professional All-Payer claims processing. Topics to be covered include setting up the
Payer, Provider, and Patient (optional) reference files. A section on claim import considerations
is included for users who will be importing claims from an upstream claims management
system. Finally, a section covering considerations for claims preparation and transmission
should be reviewed.
Attention: Your distributor may have already completed some of the setup steps
described in this section. Supplement this setup topic with any installation notes
provided by your distributor. If you are in doubt about exactly which steps you need to
perform, contact your distributor for assistance.
Tip: You may want to print this help topic and refer to the printed version as you perform
these setup steps. You can check off the steps as they are completed. This technique
also frees you to jump around between on-line help topics without losing your place in
the setup procedure. To print the topic, just click the "Print" button at the top of this online Help screen.
Payer Reference File Setup
This section describes the process of setting up the Payer reference file. This file contains
information about the valid payers in your system. All payers to be specified on your
Professional claims must exist in the Payer reference file (with the exception of a special
"dump" payer). Complete the following steps as needed:
Tip: You may want to refer to the "Adding and maintaining payers" topic for more
information on entering Payer records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Payer" tab to display a list of all
existing Payer records.
Attention: One or more Payer records may already exist in the system if your
distributor has already setup this reference file for you. Consult the distributor's
installation notes or contact your distributor for assistance before continuing this
Payer setup procedure.
2) Click the "New" button to display the Payer Information form. Enter the new payer’s
information, taking advantage of the built-in lookups where possible (by pressing the "F2"
key or right-clicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The "Payer ID", "LOB", and "Usage" fields together serve as the identification "key" for
this Payer record. A specific "Payer ID / LOB" combination may exist for a maximum of
two Payer records. If two such Payer records are defined, then their "Usage" settings must
not overlap. Valid "Usage" settings include "U" (Institutional use only), "H" (Professional
use only), and "B" or blank (unrestricted use). The only valid situation where two Payer
20
PC-ACE Pro32 Setup Procedures
records with the same "Payer ID / LOB" combination may exist is when one of the records
specifies a "Usage" value of "U" (Institutional use only) and the other record specifies a
"Usage" value of "H" (Professional use only). This feature permits Payers for shared LOBs
such as Commercial (COM) to optionally have distinct settings and PrintLink matching
strings for Institutional versus Professional use.
An individual Payer record must be setup for each line-of-business (LOB) handled by that
payer. For example, if payer "12345" will receive both Medicare and Medicaid claims, then
two Payer records must be added - both with Payer ID = "12345", one with LOB = "MCB",
and the other with LOB = "MCD".
3) Click the "Save" button to save the new Payer record. An edit validation process will be
performed to check for problems with the payer information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Payer record
should now be visible in the Payer list.
Note: If you plan on using the PrintLink feature of PC-ACE Pro32 to import claims
from "print image" files, then you will also need to add PrintLink Matching
Description strings to this Payer record. The "Claim Import Considerations" section
later in this topic will lead you through this process.
4) Repeat the relevant steps to create additional Payer records as needed. This may include
records for the same payer (and different LOBs) or records for additional payers.
5) When all desired Payer records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
Provider Reference File Setup
This section describes the process of setting up the Professional Provider reference file. This
file contains information about the valid providers in your system. All providers for whom you
will be billing Professional claims must exist in the Professional Provider reference file. The
Professional Provider reference file is organized such that each record describes a valid
provider for a single line of business (LOB). This organization allows for greater flexibility in
specifying Provider IDs and support information (Tax ID, address, etc) that can vary across
multiple LOBs for a single provider. Complete the following steps as needed:
The Professional provider structure defines 3 distinct provider types – (1) Provider Groups, (2)
Individual Providers Within A Group, and (3) Solo Providers. Professional claims require a
"billing" provider that can be either a "group" or "solo" provider (but not an "individual within a
group"). The Professional claim entry provider lookups and claim editing process will enforce
this requirement. You will be required to assign one of the 3 provider types to each provider
you add during this setup procedure.
Tip: If it is not clear which type is appropriate in each instance, you may want to refer to
the "Adding and maintaining providers (Professional)" topic for a more complete
description of the various provider types. If you do, make sure and return to this topic to
continue the setup steps. If you are sill unsure, contact your distributor for assistance.
To setup the Professional Provider reference file, complete the following steps:
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Provider (Prof)" (or just
"Provider") tab to display a list of all existing Provider records.
2) If you have just installed PC-ACE Pro32, the Provider list should be empty. If so, skip to the
next step. If the list is not empty, contact your distributor to confirm that the existing Provider
records can be safely deleted. To delete a Provider record, select the desired record in the
list and click the "Delete" button. Click the "OK" button on the Provider Deletion
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PC-ACE Pro32 User's Manual
Confirmation form to confirm the deletion request. You must delete all "Indiv" type Provider
records before deleting "Solo" and "Group" type Provider records. Make sure the list is
empty before continuing with the next step.
3) Click the "New" button to display the Professional Provider Information form. Enter the first
provider's information, taking advantage of the built-in lookups where possible (by pressing
the "F2" key or right-clicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
4) Select the desired "Provider Type" and enter the provider's name, address and contact
information. Enter the Provider ID in the "Provider ID/No." field and the line of business in
the "LOB" field. The "Payer ID" field is only needed if you want to restrict assignment of this
provider to a specific payer. Normally, the "Payer ID" field will be left blank. You can also
leave the "Tag" field blank. Enter a unique "Group Label" for the first "group" provider
record defined for each group. When adding an "individual in group" provider record,
perform a lookup in the "Group Label" field and select the group in which this individual
provider will be a member. Complete entry of the remaining provider fields as desired.
5) Click the "Save" button to save the new Provider record. An edit validation process will be
performed to check for problems with the provider information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Provider record
should now be visible in the Provider list.
6) Repeat the last few steps to add each additional Professional Provider record. Now each
time you click the "New" button, you will be prompted to select whether you want a
completely new provider (all fields blank to start with), or whether you would like to inherit
the name/address information from the currently selected provider. If you choose the
"inherit" option, you will also have the option to "associate" the new provider record with the
selected provider record. Provider records should be "associated" when they represent the
same entity. For example, if a solo provider supports multiple lines of business, one "solo"
provider record for each LOB should be created, and these related provider records should
be "associated" with each other. The "inherit" and "associate" options can be a real
timesaver when setting up providers that support multiple lines of business. In this scenario,
select an existing provider in the list, click the "New" button, and choose the "inherit" and
"associate" options. You will see that the top portion of the Provider Information form will be
completed automatically. Simply tab through or overwrite the "Provider ID/No." field (may
be the same or different), enter a unique line of business identifier in the "LOB" field, and
click the "Save" button.
7) When you have finished adding Professional Provider records, you should have one record
for each applicable line of business (LOB) for each "solo", "group", or "individual in group"
provider entity. When all desired Provider records have been added, click the "Close"
button on the Reference File Maintenance form to return to the PC-ACE Pro32 Main
Toolbar.
Patient Reference File Setup
This section describes the process of setting up the Patient reference file. Setup of the Patient
reference file is optional. If you choose to setup patients, the complete patient list will be
accessible during claim entry using the variable-list lookup feature. When a patient is selected
from the lookup list during claim entry, all applicable patient information will be automatically
loaded into the appropriate claim form fields. Complete the following steps as needed:
22
PC-ACE Pro32 Setup Procedures
Tip: You may want to refer to the "Adding and maintaining patients" topic for more
information on entering Patient records. If you do, make sure and return to this topic to
continue the setup steps.
1) From the PC-ACE Pro32 Main Toolbar, click the "Reference File Maintenance" button to
display the Reference File Maintenance form. Select the "Patient" tab to display a list of all
existing Patient records.
2) If you have just installed PC-ACE Pro32, the Patient list should be empty. If so, skip to the
next step. If the list is not empty, any existing Patient records are likely there as samples
only. Once you have confirmed that this is the case, delete all sample Patient records. To
delete a Patient record, select the desired record in the list, click the "Delete" button, and
confirm the deletion.
3) Click the "New" button to display the Patient Information form. Enter the patient information,
taking advantage of the built-in lookups where possible (by pressing the "F2" key or rightclicking the mouse).
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key)
to provide a visual indication of all fields that support lookups. Press the "ESC" key to
turn off the flashing indicator.
The Patient reference file contains general patient information as well as optional primary,
secondary, and tertiary insured details. Enter as much information as you have available
for the patient.
4) Click the "Save" button to save the new Patient record. An edit validation process will be
performed to check for problems with the patient information. When prompted, correct any
missing or invalid field values (if present) and re-save as needed. The new Patient record
should now be visible in the Patient list.
5) Repeat the relevant steps to create additional Patient records as needed.
6) When all desired Patient records have been added, click the "Close" button on the
Reference File Maintenance form to return to the PC-ACE Pro32 Main Toolbar.
User Account Setup
PC-ACE Pro32 requires that a valid login and optional password be entered by anyone
desiring access to the system. The system administrator must set up a "user" account for each
person that will use PC-ACE Pro32. The user account specifies the user's login/password
values and defines which activities the user has permission to perform. As shipped, PC-ACE
Pro32 is configured with a single default user with full system access rights. The default user's
User ID is "SYSADMIN" and password is "SYSADMIN" as well. Complete the following steps
to add additional user accounts:
Tip: You may want to refer to the "Adding or modifying a system user" topic for more
information on adding and maintaining users. If you do, make sure and return to this
topic to continue the setup steps.
1) Select the main "Security" menu from the PC-ACE Pro32 Main Toolbar and choose the
"Add/Update User" item. The Security List form will display a list of all existing user
accounts.
2) To add a new user account, click the "New" button on the Security List form and assign the
user a User ID, Password and Name. Assign permissions to this user and click the "OK"
button to save the new user record.
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Tip: Check the checkbox next to the permission to allow access to the activity. Click
the "Check All" and "Clear All" buttons to quickly check or un-check all user
permission checkboxes.
3) Repeat the previous step to create additional user accounts.
Note: If changes are made to a user profile, the changes will not go into effect until the
next time that user logs into system. Select the "Logout Current User" item on the
main "Security" menu to manually log out without exiting the system.
Attention: You should change the default user's password as soon as possible if
you are concerned about controlling user access at your facility.
Claim Import Considerations
This section describes setup considerations that should be reviewed only if you intend to
import claims into PC-ACE Pro32 from an upstream system. If you will not be importing claims,
skip this section entirely. Three methods are available for importing claims - Print Image
(PrintLink), Intermediate Delimited Format, and Electronic Media Claims (EMC) Format.
Note: Getting setup to import claims into PC-ACE Pro32 typically involves coordination
with your distributor. If you are interested in importing claims using the PrintLink print
image method, but your distributor does not provide PrintLink support, ask that they
refer you directly to the software manufacturer for assistance. PrintLink functionality
may be licensed and supported as an "add-on" to your base PC-ACE Pro32 system.
Tip: You may want to refer to the "Importing claims" topic for a discussion of these claim
import methods. If you do, make sure and return to this topic to continue the setup steps.
Review only the setup considerations applicable to the claim import method you intend to use.
Print Image (PrintLink) - imports claims from a print image file. If using this claim import
method, complete the following steps:
1) Have your distributor perform a one-time "PrintLink mapping" procedure on a
sample print image file that you have supplied. This mapping process defines the
template used to extract and interpret fields from your print image file. Since all
upstream systems print claims in a slightly different format, this mapping process is
required to build your custom template.
2) Obtain the resulting "map" file from your distributor. This file is typically named
"h1500.map", but can be any valid filename with a ".map" extension. The map file
must be placed in the server's "winpcace\imp1500" directory.
3) Confirm the existence of the required "map control" file. This file provides a control
interface between the output of the PrintLink translator and the PC-ACE Pro32 claim
import routines. The map control file is always named "mapcntlh.win", and should be
located in the server's "winpcace\imp1500" directory.
4) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the print file to
specific Payer reference file records. Refer to the "Adding and maintaining payers"
topic for details on setting up your PrintLink Matching Description strings.
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PC-ACE Pro32 Setup Procedures
5) Each time you want to import claims, copy the new print image file generated by your
upstream system into the server's "winpcace\imp1500" directory. The first line of the
map file provided by your distributor dictates what the print image file must be named
(typically "h1500.prt").
Intermediate Delimited Format - imports claims from a file in "intermediate delimited"
format. If using this claim import method, complete the following steps:
1) Work with your distributor to develop the programs necessary to produce a file in
"intermediate delimited" format from your upstream system. Your distributor should
have detailed specifications of this internal file format. Verify that the generated files
meet these specifications.
2) Confirm the existence of the required "map control" file. This file provides a control
interface between the intermediate delimited file and the PC-ACE Pro32 claim import
routines. The map control file is always named "mapcntlh.win", and should be
located in the server's "winpcace\imp1500" directory.
3) Setup all required PrintLink Matching Description strings in the Payer reference file.
These strings are used to match payer descriptions from claims in the intermediate
delimited file to specific Payer reference file records. Refer to the "Adding and
maintaining payers" topic for details on setting up your PrintLink Matching Description
strings.
4) Each time you want to import claims, copy the new intermediate delimited file
generated by your upstream system into the server's "winpcace\imp1500" directory.
The file must be named "plink.out".
Electronic Media Claims (EMC) Format - import claims from a file in Electronic Media
Claims (EMC) format. If using this claim import method, complete the following steps:
1) Confirm that your upstream system is capable of producing a supported version
Electronic Media Claims (EMC) format file. Contact your distributor for the list of
supported EMC file versions.
2) Each time you want to import claims, copy the new EMC file generated by your
upstream system into the server's "winpcace\imp1500" directory. The file must have
a ".dat" file extension (e.g., "EMC320.DAT").
Claim Prepare & Transmit Considerations
This section describes setup considerations that should be reviewed before you attempt to
prepare and transmit claims using PC-ACE Pro32.
Note: Your distributor may have already performed some (or all) of this setup for you.
Consult your distributor's installation instructions or contact the distributor if it is unclear
how to proceed.
1) Setup default Professional submitter information in the PC-ACE Pro32 Submitter reference
file. Information from this reference file is required during preparation of Electronic Media
Claims (EMC) files. Consult your distributor's installation instructions or contact the
distributor for assistance in setting up this critical reference file.
Tip: Refer to the "Submitter File Maintenance" topic for more information on setting
up the default Submitter record.
2) If required by your distributor, setup default Professional data communications
parameters in the PC-ACE Pro32 Data Communications reference file. This reference file
contains the Professional data communications parameters exported to the "bsdatcom.dat"
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file prior to the launch of any external data communications program (e.g., file
transmission). These parameters are used by the third-party data communications program
to control the file transmission, etc.
Tip: Refer to the "Data Communications File Maintenance" topic for more information
on setting up the default Data Communications record.
This completes the required setup steps to ready PC-ACE Pro32 for Professional All-Payer
claims processing.
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Main Toolbar & Forms
The PC-ACE Pro32 Main Toolbar
All PC-ACE Pro32 functions are available from the main toolbar action buttons and menu. This
toolbar consumes only a small amount of your valuable desktop space, and can be set to dock
automatically to any desktop corner (or float if desired). The toolbar action buttons provide
quick access to:
Import, enter, modify, process, and prepare Institutional claims.
Import, enter, modify, process, and prepare Professional claims.
Maintain all supporting reference files (patient, payer, provider, etc.).
Launch your claim submission and related data communication software.
Schedule delayed and daily recurring claim activities.
Launch the ANSI-835 Electronic Remittance program.
Perform system backup/restore and other maintenance functions.
Send support mail to your distributor (may not be available).
The main "File" menu provides access to the Preferences dialog used to customize PC-ACE
Pro32 to your particular installation and style. The main "Security" menu provides access to the
system's user maintenance and security features and also allows the current user to logout. The
main "Help" menu provides access to this on-line help system, the Online Software Update
utility, and the PC-ACE Pro32 "About" box (containing the PC-ACE Pro32 program version
number and important copyright information).
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Institutional & Professional Claims Menus
Most claim activities in PC-ACE Pro32 are initiated from one of 2 essentially identical claim
activity menu forms (one each for Institutional and Professional claim activities). The menu's
action buttons provide access to the most commonly used claim activities:
Import claims from a print file (PrintLink) or alternate source.
Enter claims manually.
Maintain existing claims from a comprehensive list.
Process imported or reactivated claims automatically.
Prepare claims into an EMC file for transmission.
The form's "View" menu provides access to the most recent claim import, claim status request,
and eligibility benefit request reports, as well as the claim activity log. The "Attachments" menu
(Institutional only) includes options to create and maintain Home Health Plans of Care (Form
No. CMS-485 / CMS-486). In addition, a few handy claim activity maintenance functions are
available from the "Maintain" menu. These include the ability to reverse the most recent claim
import run, to review and reactivate previously prepared EMC files for re-transmission, to review
and maintain ANSI-997/999 transmission acknowledgment files, to launch the PC-ACE Pro32
Report Manager, to add and maintain patient eligibility benefit requests, to prepare an ANSI-270
eligibility benefit request file for transmission, to view and maintain ANSI-271 eligibility benefit
response files, to prepare an ANSI-276 claim status request file, and to review and maintain
ANSI-277 claim status response and claim acknowledgment files. Note: Certain capabilities
may not be available on your installations. Only those capabilities supported by your distributor
will be visible in these menus.
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Main Toolbar & Forms
Claim List Form Features
The PC-ACE Pro32 Claim List form provides a versatile interface from which the user can
create, list, modify, print, and otherwise maintain claims. Click either the "Institutional Claims
Processing" button or "Professional Claims Processing" button on the PC-ACE Pro32 Main
Toolbar to open the corresponding Claims Menu form. Then click the "List Claims" button on
the Claims Menu form to open the desired Claim List form. You may reposition and resize this
form if desired. The list can be easily sorted and filtered to display only the claims of interest.
The Institutional and Professional Claim List forms are virtually identical. All procedures
described in this section pertain to both claim types unless otherwise specified.
Sorting Claims
The claim list may be sorted by Patient Name, Patient Control Number (PCN), Entry Date,
Service Date and Transmit Date. Simply select the desired sort order from the available "Sort
By" radio buttons.
Filtering Claims
The claim list may be filtered to display a select subset of claims by manipulating the "Claim
List Filter Options" drop-down lists. Basic filter options include:
Location - filters the claim list to include only claims in the "to be transmitted" (CL),
"transmitted" (TR), or "paid" (PD) locations. An additional "transmitted + paid" (TR/PD)
selection is available to display both transmitted and paid claims. This selection may
provide a more comprehensive view of the claims during payment posting, for example.
Status - filters the claim list to include only claims assigned a specific status. The
possible status codes are: "clean/ready" (CLN), "deleted" (DEL), "has fatal errors"
(ERF), "has errors" (ERR), "held" (HLD) and "unprocessed" (UNP).
Note: Note that selecting a status of "DEL" is the only way to view "deleted" claims
(which can be recovered until they are purged from the system).
LOB - filters the claim list to include only claims for a specific line of business.
In addition to these basic filter options, the Claim List form also provides a number of
Advanced Filter Options. These advanced options permit filtering on the claim's patient,
payer, provider, date ranges, batch information, bill type and numerous other criteria. When
multiple filter criteria are specified, only those claims that meet all filter criteria will be
displayed.
Note: The initial display of transmitted/paid claims in the Claim List form may be
optionally limited to only the most recently transmitted claims. Refer to the PC-ACE
Pro32 Miscellaneous preferences topic for a description of this feature, and to review
the current settings. Limiting the number of transmitted/paid claims being displayed in
the claim list can improve the list's responsiveness in some situations. To display
transmitted/paid claims older than the current transmit date window, simply click the
"Advanced Filter Options" button and enter the desired Transmit Date range.
Claim Actions
The Claim List form may also be used to perform specific actions on any individual claim or a
group of selected claims. To perform an action on an individual claim, simply select the claim
from the list and click the desired action button (along the lower edge of the form). The
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complete list of claim actions can be accessed from the Claim List form's main "Actions" menu
or from the convenient pop-up menu (accessed by right clicking the mouse over the selected
claim). Available claim actions include:
Creating New Claims -- Click the "New" button (or choose the "Create New Claim"
action) to create a new claim. See the "Adding a new claim" topic for more details.
Viewing/Modifying Claims -- Click the "View/Update" button (or choose the
"View/Update Selected Claim" action) to view and/or modify the selected claim. See
the "Institutional Claim Form" or "Professional Claim Form" topics for details on using the
PC-ACE Pro32 claim entry forms.
Tip: The View/Update action is the default claim action. In addition to the
techniques described above, this action can also be invoked by double-clicking on
the desired claim record or by selecting the desired record and pressing the
"ENTER" key.
Tip: Holding down the "SHIFT" key while invoking the View/Update action on an
eligible claim will force an automatic save attempt on the claim. This is a shortcut
technique equivalent to invoking the View/Update action and subsequently clicking
the "Save" button on the claim entry form. It minimizes the keystrokes required to
work claims from the Claim List form. Eligible claims are those in the "to be
transmitted" (CL) location with a status of either "unprocessed" (UNP), "has errors"
(ERR), or "has fatal errors" (ERF).
Deleting Claims -- Click the "Delete" button (or choose the "Delete Selected Claim"
action) to delete the selected claim. Deleted claims are assigned a "DEL" status, and
can be recovered (i.e., "un-deleted") if needed. See the "Purging Claims" action
description below for instructions on permanently removing claims from the PC-ACE
Pro32 database.
Copying Claims -- Click the "Copy" button (or choose the "Copy Selected Claim"
action) to copy the selected claim. When copying a single claim, the claim entry form will
be displayed containing the details of the newly copied claim. The claim copy function
may be used to create a duplicate of a previously transmitted claim for repeat billing in a
subsequent period, or for submission of a Coordination of Benefits (COB) claim to the
secondary or tertiary payer.
Holding Claims -- Choose the "Hold Selected Claim" action to change the status of the
selected claim to "hold" (HLD). Held claims are not considered for future claim activities
such as automated claim processing or claim preparation.
Releasing Claims -- Choose the "Release Selected Claim" action to release a
previously held claim. In addition to releasing the claim, this action also sets the status of
the selected claim to "unprocessed" (UNP).
Printing Claims -- Choose the "Print Selected Claim" action to print the selected claim.
Claims may be printed using either a plain paper image overlay technique or the
traditional pre-printed forms method. See the "Printing claims" topics for more details.
Posting Claim Payments -- Choose the "Show Selected Claim Payments" action to
post, view, or modify payments for the selected claim. Claim posting may also be
performed from the appropriate claim entry form. See the "Posting claim payments
(Institutional)" and "Posting claim payments (Professional)" topics for more details.
Purging Claims -- Choose the "Purge Selected Claim" action to purge the selected
claim. Claims in the "to be transmitted" (CL) location must be deleted before being
purged.
Attention: Purged claims are permanently deleted from PC-ACE Pro32 …
they cannot be recovered.
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Main Toolbar & Forms
Reactivating Claims -- Choose the "Reactivate Selected Claim" action to reactivate
the selected claim. This action will move the previously transmitted claim from the
"transmitted" (TR) or "paid" (PD) location into the "to be transmitted" (CL) location. The
reactivated claim will be assigned the "unprocessed" (UNP) status. See the
"Reactivating previously transmitted claims" topic for more details.
Archiving Claims -- Choose the "Archive Selected Claim" action to move the selected
claim from the current claim database to the open claim archive database. Only claims in
the "transmitted" (TR) and "paid" (PD) locations are eligible for archiving. Refer to the
"Archiving and unarchiving claims" topic for more information on the PC-ACE Pro32
claim archiving feature.
Unarchiving Claims -- Choose the "Unarchive Selected Claim" action while viewing
the claims in an open claim archive to move the selected claim from the archive
database to the current claim database. Refer to the "Archiving and unarchiving claims"
topic for more information on the PC-ACE Pro32 claim archiving feature.
Setting Claim Media -- Choose the "Set Selected Claim Media" action to designate the
selected claim for either "electronic" or "paper" submission. Only claims with a media
setting of "electronic" (E) will be eligible for preparation into an EMC file. Claims with a
media setting of "paper" (P) can be printed and submitted in hardcopy form. When a
"paper" claim is printed, you will be given the option to move the claim from the "to be
transmitted" (CL) location to the "transmitted" (TR) location automatically.
Note: Support for "paper" claims may be disabled by the distributor. If the "Set
Selected Claim Media" action item is not visible, then your system does not
support paper claim processing and all claims must be submitted electronically.
Requesting Claim Status -- Choose the "Request Selected Claim Status" action to
add the selected claim to the claim status request queue. Status requests can only be
made for claims in the "transmitted" (TR) and "paid" (PD) locations. Any number of
claims can be queued using this action item. Once all desired claims have been queued,
refer to the "Preparing claim status request files for transmission" topic for instructions on
preparing the ANSI-276 claim status response file.
Note: Support for the ANSI-276/277 claim status request/response feature may
be disabled by the distributor. If the "Request Selected Claim Status" action
item is not visible, then your system does not support the claim status
request/response feature.
Show Selected Claim Status History -- Choose the "Show Selected Claim Status
History" action to view and maintain the claim status request/response history for the
selected claim. This action is available for claims in the "transmitted" (TR) and "paid"
(PD) locations only. Refer to the "Viewing and maintaining the claim status
request/response history" topic for more information on how to use the Claim Status
Request/Response History form.
Note: Support for the ANSI-276/277 claim status request/response feature may be
disabled by the distributor. If the "Show Selected Claim Status History" action
item is not visible, then your system does not support the claim status
request/response feature.
Refreshing the Claim List -- Choose the "Refresh Claim List" action (or press the "F5"
function key) to refresh the current Claim List form contents. This action can be useful in
a multi-user installation to be sure that the claim list properly reflects claim additions
and/or modifications made by other users.
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Note: You will notice that only applicable actions are enabled for use in the main
"Actions" menu or pop-up menu. For example, it makes no sense to "reactivate" a
claim that has yet to be transmitted, so this action will be disabled for claims in the "CL"
location.
Actions on Multiple Claims
Some actions can be performed on multiple claims at once. Multiple claim selection is
accomplished by "checking" the claim of interest and subsequently performing one of the "…
All Checked Claims" actions. To check a claim, click the left mouse button over the checkbox
in the first column of the desired list row. Alternatively, all claims in the current list can be
checked using the "Check All Claims" item from the list's pop-up menu. Use the flexible Claim
List form filter techniques to display only the subset of claims to be printed, deleted, held, etc.
Then simply check all claims and perform the desired action on all checked claims at once.
Tip: Use the "Check All Claims From Selected Transmission" filter option to quickly
identify (i.e., "check") all claims that were included in a specific transmission file. This
filter option can be especially useful if, for example, it becomes necessary to reactivate
all claims from a recent transmission file. A warning will be displayed if one or more of
the claims from the selected transmission file are no longer present in the claim list. This
filter option can be accessed from the Claim List form's main "Filter" menu, and will be
available only when viewing claims in the "transmitted" (TR) and "transmitted + paid"
(TR/PD) locations.
Claim List Field Customization
The Claim List form field definitions are highly customizable. Many of the Institutional and
Professional claim data elements may be included (or excluded) from the list. The display
order, column width, and column headings of each selected field may also be customized. See
the "Claim List Preferences" topic for a description of the list customization process. NOTE:
Some distributors may disable this customization feature.
Claim List Filter Menu
Several claim list filtering and related functions are accessible from the Claim List form’s main
"Filter" menu:
Clear Filters – Clears any existing filter criteria and refreshes the claim list to display all
claims in the selected location.
Advanced Filter Options – Opens the Advanced Claim List Filter Criteria for to permit
filtering on the claim's patient, payer, provider, date ranges, batch information, bill type
and numerous other criteria. When multiple filter criteria are specified, only those claims
that meet all filter criteria will be displayed.
Note: You may observe that the Transmit Date is being populated automatically
even when you've cleared the advanced filter settings. This is normal when the
Claim List form is configured to limit the initial display of transmitted/paid claims.
Refer to the PC-ACE Pro32 Miscellaneous preferences topic for a description of
this feature, and to review the current settings.
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Check (Uncheck) All Claims – Permits the user to "check" (or "uncheck") all claims
currently displayed in the claim list – presumably in anticipation of some action to be
Main Toolbar & Forms
performed on this block of claims. See the "Actions on Multiple Claims" section above for
more information.
Check All Claims From Selected Transmission – Provides an easy way to "check" all
claims included in a previous transmission file. The Institutional or Professional Claim
Transmission Log form will display a list of recent transmission files (with the most recent
automatically selected). Select the desired transmission file entry and click the "Select"
button. Upon return to the Claim List form, the program will automatically check all
claims included in the selected transmission. This feature is especially useful in
situations where all claims from a previous transmission need to be reactivated,
modified, and then re-prepared into a new transmission file. After selecting the desired
transmission file entry, the user would simply choose the "Reactivate All Checked
Claims" item from the form's main "Actions" menu to complete the reactivation process.
Refer to the "Reactivating previously transmitted claims" topic for more information on
reactivating previously transmitted claims.
Check All Queued Claims For Status Request – This is simply a convenience feature
that will "check" all claims that are currently queued for inclusion in the next ANSI-276
claim status request file. It can be used as a reminder of which claims have already been
added to the queue. See the "Preparing claim status request files for transmission" topic
for information on how to use the ANSI-276/277 claim status request/response feature.
Clear Claim Status Request Queue – Clears the ANSI-276 claim status request queue.
See the "Preparing claim status request files for transmission" topic for information on
how to use the ANSI-276/277 claim status request/response feature.
Note: Support for the ANSI-276/277 claim status request/response feature may be
disabled by the distributor. If the "Check All Queued Claims For Status
Request" and "Check Claim Status Request Queue" action items are not visible,
then your system does not support the claim status request/response feature.
Claim List Reports
Several reports and special print functions are accessible from the Claim List form’s main
"Reports" menu:
Print Claim Detail Report – Select this item to print a detailed report of either all "listed"
or all "checked" claims. If one or more claims in the list are "checked", then only the
checked claims will be included in the report. If no claims are checked, then the report
will include all listed claims. The previewed report may be printed if desired by clicking
the printer button at the top of the report preview form. To print a detailed report on a
specific subset of claims, first use the Claim List form's filter capabilities to display only
the claims of interest. If even more specific identification is required, then simply "check"
only those claims that are to be included in the report.
Print Claims for Paper Submission – Select this item to print all (or a subset) of claims
currently eligible for paper submission. A claim is eligible for paper submission if it has a
media setting of "paper" (P), resides in the "to be transmitted" (CL) location, and has a
"clean" (CLN) status (or, optionally, a "non-fatal errors" (ERR) status). When printing
claims for paper submission, you will have the option to print all eligible claims or just
eligible claims for a selected payer. You will also choose whether or not to include
eligible claims with a status of "non-fatal errors" (ERR). After each eligible claim is
printed, you will be prompted to automatically move the claim to the "transmitted" (TR)
location. Since paper claims will never be prepared into an EMC file, this prompt
provides the only available mechanism for moving these claims out of the "to be
transmitted" (CL) location. When multiple paper claims are eligible for submission, you
may use the convenient "Yes To All" ("No To All") button to move (not move) all eligible
paper claims to the "transmitted" (TR) location after printing.
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Tip: When printing claims for paper submission, you will also have the option to
print these same claims on behalf of their alternate (non-submission) payers. This
feature can be useful if you also need to submit paper claims to the secondary or
tertiary payers, for example. Refer to the "Printing claims" topic for more details on
the alternate payer printing feature.
Note: Support for "paper" claims may be disabled by the distributor. If the "Print
Claims for Paper Submission" menu item is not visible, then your system does
not support paper claim processing and all claims must be submitted electronically.
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Main Toolbar & Forms
The Institutional Claim Form
The Institutional Claim Form provides access to all data elements of an Institutional claim. New
claims are entered and existing claims are viewed and/or modified from this form. The
Institutional Claim Form has been designed to provide a data entry flow resembling that of the
printed Institutional (CMS-1450) claim form. Claim fields are grouped logically on these major
tabs:
Patient Info & Codes - includes fields for general claim and patient information. Also
includes the Condition, Occurrence, Span, and Value code fields.
Billing Line Items - includes all claim line item fields, extended line item fields, line-level
provider fields, and line-level MSP/COB fields. This major tab contains a number of
second-level tabs to accommodate the additional line-level fields.
Payer Info - includes payer, provider, insured, and employer fields for the primary,
secondary, and tertiary payers.
Diagnosis/Procedure - includes fields for diagnosis codes, procedure codes and dates,
claim-level provider information, and a few miscellaneous data elements.
Diag/Proc (2) - includes fields for additional diagnosis codes, procedure codes and
dates, and claim-level provider information.
Extended General - includes additional patient and general claim-level fields.
Ext. General (2) - includes additional Condition, Occurrence, Occurrence Span and
Value code fields and most reserved CMS-1450 form locator fields.
Extended Payer - includes less frequently used payer, insured, and authorization fields
for the primary, secondary, and tertiary payers. Also includes fields for Medicare
Secondary Payer (MSP) and other secondary claims where Coordination of Benefits
(COB) information is required. This major tab consists of a number of second-level tabs
that provide access to this extended information in a logical and efficient manner.
Click the appropriate tab or simply press the "PAGE UP" and "PAGE DOWN" keys to move
between these major claim form sections.
Entering Claim Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Use the "UP ARROW" and
"DOWN ARROW" keys to move up and down through the claim form fields, respectively.
A number of productivity enhancing features are available during claim data entry:
Fixed-List Lookups - The claim entry form supports fixed-list lookups on many of the
claim's fields. Fixed-list lookups apply to fields whose list of valid values can be
determined in advance. For example, "Patient Sex" typically has 3 possible values: "M"
(male), "F" (female), and "U" (unknown).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the claim form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The claim entry form supports variable-list lookups on a
number of the claim's fields. Variable-list lookups apply primarily to fields whose values
are selected from reference files. Most variable-list lookups use other claim field values
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(the specified claim "LOB", for example) to filter the presented list. For example, provider
lookups attempt to present only those provider records applicable to the claim being
entered. In addition, variable-list lookups often retrieve data used to fill in other claim
form fields. For example, selection of a Patient from the variable-list lookup completes
numerous patient-related fields on the claim. Access variable list lookups using the same
method described above for fixed-list lookups.
Recurring Field Sets - Field "sets" consist of two or more logically-related fields. For
example, most ANSI/X12 reference identifiers include an identification number, a type
code (qualifier), and in some situation a payer identifier as well. It is often a requirement
to support a variable number of occurrences of a particular field set. The claim entry form
provides an intelligent combo (i.e., dropdown) control to allow entry and maintenance of
such recurring field sets.
To identify a recurring field set, look for the
selector which will be positioned adjacent
to the rightmost field in the set. The recurring field set and associated selector function in
the following manner:
As the user tabs normally away from the last field in the set, the focus will
automatically return to the first field in the set and the next data occurrence will be
displayed. Only when all occurrences have been displayed will the focus move to the
next field on the claim entry form. This behavior permits the user to view all
occurrences without using the mouse, and also provides an opportunity to enter new
data if desired.
Click the selector graphic to open the dropdown list and display all existing data
occurrences. A vertical scrollbar will appear as needed to permit access to all
occurrences. Select an entry from the list or press the "ESC" key (or click elsewhere
on the form) to close the dropdown list. The data values corresponding to the
selected entry will be displayed in the field set and are now available for editing as
needed.
To add a new occurrence to a field set, either tab through all existing occurrences
until an empty field set is displayed or simply select the "[Enter New ...]" item in the
dropdown list.
Press the "F7" key while positioned on any field in the set to delete the selected
occurrence. You will be prompted to confirm the deletion.
If the focus moves away from a recurring field set while an empty occurrence is
displayed, the field set will automatically display the data for the first occurrence, if
any, rather than leave the screen fields blank.
The edit validation process understands the recurring nature of these special field
sets, and will automatically reposition to the proper occurrence when displaying edit
validation errors.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Intelligent Groups Tabs - The Institutional claim form contains a number of field
"groups". Examples of such groups include Condition, Occurrence, Span, Value,
Diagnosis, and Procedure codes. Fields in these groups are always completed
sequentially. Therefore, when a field in one of these groups is left empty, it can be
assumed that data entry in the group is complete. When the "TAB" key is pressed, the
remaining fields in that group will be skipped and the cursor will be positioned on the first
field in the tab sequence beyond the group fields.
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Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most claim form fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
Descriptive Field Hints - Most claim form fields have field hints that provide a brief
description of the field's purpose. These hints are often called "fly-over" hints, since they
become visible when the mouse pointer moves over the specified field (without actually
selecting the field). This feature can be disabled in the general preferences settings if
desired.
Line Item Scrolling - The Billing Line Items tab displays 8 claim lines at a time. For
claims that contain more than 8 line items, the user may scroll through the claim line
items one line at a time or one page (i.e., 8 lines) at a time using the buttons provided
along the right edge of this tab.
Tip: You can also use the up/down arrow keys to move from line to line, scrolling
when appropriate. Type "<ALT><PAGE UP>" (press the "Page Up" key while
holding the "ALT" key down) or "<ALT><PAGE DOWN>" to scroll up/down through
all claim line items one page at a time.
Line Item Features - The following productivity features are available on the Billing Line
Items tab:
Current Line Tracking - The Billing Line Items tab contains a number of secondlevel tabs. The first second-level tab (Line Item Details) displays the basic line item
fields available on the hard-copy Institutional claim form. The remaining second-level
tabs are linked to the currently selected line on the Line Item Details tab. As the
cursor moves from one line to another on the Line Item Details tab, the remaining
second-level tabs will track the new current line. This technique provides an efficient
method of providing access to a large number of data elements on a potentially large
number of claim lines. Notice that the Extended Details and Ext Details 2 tab
captions always report the current line for reference.
Line Duplication - Press the "F5" key while positioned on any field on a line to copy
the values in all fields of the previous line into the current line.
Field Duplication -- Press the "F4" key while positioned on a specific field on a line to
copy the value of that single field from the previous line into the current line.
Line Deletion - Press the "F7" key while positioned on any field on a line to delete the
line. You will be prompted to confirm the deletion. Alternatively, enter the value
"*DEL*" (that's an asterisk plus "DEL" plus another asterisk, without the doublequotes) into the HCPCS field on a claim line to delete the line.
Note: Claim lines are automatically re-sequenced by Revenue Code when a
claim is saved. As such, there is no need to provide line rearrangement
capabilities.
Advance To Next Line - Press the "F8" key while positioned on any field on a line to
automatically advance the cursor to the first field of the next line, skipping over any
remaining fields on the current line.
Jump To Narrative - Press the "<ALT>N" key combination while positioned on any
field on a line to automatically position on the "84 - Remarks" field. Enter the desired
narrative text and press the "<TAB>" key to return to the original line field.
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Line Item Totals Recalculation – The Billing Line Items tab provides a "Recalculate"
button located near the bottom of the tab adjacent to the totals fields. Click this button to
recalculate and update the "Total Charges" and "Total Non-Covered Charges" fields
from the current claim line item charges values. NOTE: This button may not be available
on some installations.
Payer / Insured Features - The following payer and/or insured information productivity
features are available:
Quick Payer Access - Press the "<ALT>I" key combination while positioned
anywhere on the Patient Info & Codes tab to move immediately to the primary
payer's "Payer ID" field. Press the "<ALT>O" key combination to move immediately
to the secondary payer's "Payer ID" field.
Clear Payer Feature - The Payer Information tab provides a "Clear Payer" button
for each of the 3 claim payers. Click this button to clear all payer, provider, insured,
and employer fields for the associated payer.
Coordination of Benefits (COB) Support – The claim form includes fields to allow
entry of Coordination of Benefits (COB) data at both the claim and line levels when
appropriate. Enter a "Y" in the "COB?" field to make these COB-related fields available
for use. The "COB?" field is located in the upper right quadrant of the
Diagnosis/Procedure tab. See the section entitled "Coordination of Benefits" later in this
topic for details on this advanced capability.
When the focus leaves a claim form field (either by pressing the "TAB" key or clicking on a
new field), an edit validation process is performed on the field losing the focus. Edits performed
at this time are referred to as "field-level" edits. If a field-level edit validation error occurs, you
will receive an audible response and the edit validation error message will be displayed in the
lower left corner of the claim form. In addition, the focus will remain on the field so that you can
correct the problem if desired. If you choose not to correct the data at this time, simply press
the "TAB" key again to move to the next field. Refer to the "Claim & Reference File Edit
Validation" topic for a more complete discussion of the claim edit validation process.
Coordination of Benefits
The Institutional Claim Form includes fields to allow entry of Coordination of Benefits (COB)
information at the claim and/or line level. Claims submitted to secondary or tertiary payers may
be required to report the payment remittance data returned by prior payers. Medicare
Secondary Payer (MSP) claims, for example, must include specific COB information obtained
from the primary payer in order to insure prompt processing by Medicare.
Note: Since Coordination of Benefits information is not required on all claims, the
screen tabs containing COB-related fields are hidden by default. Enter a "Y" in the
"COB?" field to make these COB-related fields available for use The "COB?" field is
located in the upper right quadrant of the Diagnosis/Procedure tab.
Two distinct levels of Coordination of Benefits reporting are supported:
Claim-Level COB Reporting – Remittance data which is not specific to a particular
service line is reported at the claim level. The claim form provides claim-level COB fields
for both the primary and secondary payers. These fields are located on the "COB Info
(Primary) and "COB Info (Secondary)" sub-tabs of the Extended Payer tab.
Line-Level COB Reporting – Remittance data specific to a particular service line is
reported at the line level. The claim form provides a set of line-level COB fields for each
service line. These fields are located on the "MSP/COB" sub-tab of the Billing Line Items
tab. This sub-tab tracks the currently selected service line in the same manner as the
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other extended line item sub-tabs. The current service line is identified in the
"MSP/COB" sub-tab caption (e.g., "MSP/COB (Line 4)").
The decision to report COB information at the claim versus line level is made by the payer and
communicated to the provider via a remittance. The remittance may be in electronic (ANSI835) or paper format, and typically serves as the source for all COB data to be entered into the
claim form's COB fields.
Tip: There's no need to re-enter claims for submission to secondary payers if the
original claim was processed through PC-ACE Pro32. Simply use the Institutional
Claim List form to locate the original claim in the "TR – transmitted" location, select the
"Copy" action to create the new secondary claim, and enter the LOB applicable to the
secondary payer. Finally, enter a "Y" in the "COB?" field on the Diagnosis/Procedure
tab to activate the COB-related fields. You will then have a duplicate of the original
claim ready to add the primary payer's COB information.
The claim-level COB data is entered on the "COB Info (Primary)" and "COB Info
(Secondary)" sub-tabs of the Extended Payer tab. The purpose and use of the various field
groups on these sub-tabs are as follows:
Claim-Level Adjustments (CAS) – Permits entry of one or more claim-level
adjustments as reported by the payer. Adjustments are defined by a specific "Group"
code and "Reason" code combination. Enter these codes manually or select them from
the available lookup lists. Each claim-level adjustment must specify a non-zero "Amount"
value and may also specify an optional "Units" value.
COB / MOA Amounts – Permits entry of various general claim-level COB amount
values as well as amount values defined specifically for Medicare Inpatient Adjudication
(MIA) and Medicare Outpatient Adjudication (MOA) use. Enter or select the "Code"
which defines the amount type to be reported, and enter the corresponding "Amount"
value.
Medicare Inpatient Adjudication (MIA) Remarks Codes – Permits entry of up to 5
remarks codes for Medicare Inpatient Adjudication (MIA) use. These optional codes may
be entered manually or selected from the available lookup list.
Medicare Outpatient Adjudication (MOA) Remarks Codes – Permits entry of up to 5
remarks codes for Medicare Outpatient Adjudication (MOA) use. These optional codes
may be entered manually or selected from the available lookup list.
Claim Adjudication Date – Permits entry of the date on which the payer adjudicated the
claim. This date is typically required at either the claim or line level.
The line-level COB data is entered on the "MSP/COB" sub-tab of the Billing Line Items tab.
The purpose and use of the various field groups on this sub-tab are as follows:
Service Line Adjudication (SVD) Information – Permits entry of one or more Service
Line Adjudication (SVD) lines as reported by the payer for the current service line. The
"P/S" field identifies the payer (primary/secondary) reporting this line adjudication notice.
The revenue code reflects that of the service line being adjusted. The procedure code
and modifier fields identify the specific procedure being adjusted. The practice of
procedure code "bundling" and "unbundling" utilizes these fields to provide specific
information regarding how the payer has grouped the procedures for payment. The "Paid
Amount" indicates the amount the payer has paid on this procedure. The "Paid Units"
value permits reporting of payments for less than the originally billed units. Finally, the
"B/U Line" field identifies the service line on the original claim to which this SVD line
applies. This reference identifier should be included on the remittance, and is primarily
used in scenarios where procedure code bundling/unbundling has occurred.
Line Adjustment (CAS) & Miscellaneous Adjudication Info – Permits entry of several
additional Service Line Adjudication (SVD) fields for the current SVD line. The fields in
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this control group track the currently selected SVD line. The control group's caption
indicates the current SVD line (e.g., "(for SVD 1 above)").
Procedure Code Description – Permits entry of an optional description of the
procedure code specified on this SVD line.
Adj/Payment Date – Permits entry of the date on which the payer specified on this
SVD line adjudicated this service.
Remaining Amt Owed – Permits entry of the optional remaining amount to be paid
after adjudication by the other payer represented in this SVD line.
Line-Level Adjustments (CAS) – Permits entry of one or more line-level
adjustments as reported by the payer for the current Service Line Adjudication
(SVD) line. Adjustments are defined by a specific "Group" code and "Reason" code
combination. Enter these codes manually or select them from the available lookup
lists. Each line-level adjustment must specify a non-zero "Amount" value and may
also specify an optional "Units" value.
Tip: Fixed-list or variable-list lookups are available on many of the COB-related fields to
improve user efficiency. In addition, the standard line duplication (F5), field duplication
(F4), and line deletion (F7) functions are available on all COB-related scrolling arrays.
As an additional convenience, pressing the "F5" key while positioned on the first
Service Line Adjudication (SVD) line will populate the SVD fields with their equivalent
values from the original service line.
Present On Admission (POA) Indicators
PC-ACE Pro32 uses the 8th position of the Principal Diagnosis Code, Other Diagnosis Codes,
and External Cause of Injury (E-Code) fields to hold the "Present On Admission" (POA)
indicators. These indicators are required on certain inpatient claims, and are displayed in the
right-justified shaded area of these diagnosis code fields. Valid POA indicator values are:
Y
(Yes) Present at the time of inpatient admission.
N
(No) Not present at the time of inpatient admission.
U
(Unknown) The documentation is insufficient to determine if the condition was present
at the time of inpatient admission.
W
(Clinically Undetermined) The provider is unable to clinically determine whether the
condition was present at the time of inpatient admission or not.
1
(Unreported/Not used) Exempt from POA reporting. This code is the equivalent code
of a blank on the UB-04.
When hand-keying a claim that requires POA information, simply enter the diagnosis code
followed by a single SPACE character (to serve as a separator) and then one of the valid POA
indicator values. It is not necessary to "count spaces" between the diagnosis code and the
POA indicator. The indicator character will be automatically repositioned to the 8th position of
the diagnosis code field when the focus moves to another screen control. When selecting
diagnosis codes from a lookup list, the cursor will automatically position itself at the end of the
diagnosis code value to make it easy to append the POA indicator when appropriate. Simply
enter a single SPACE character followed by the POA indicator value.
Present On Admission (POA) information should be entered only on claims involving inpatient
admissions to general acute care hospitals or other facilities that are subject to a law or
regulation (e.g., Deficit Reduction Act of 2005) mandating collection of this information. Claim
edits exist to enforce Medicare POA reporting requirements. These edits are driven off the
"Requires POA Reporting" field on the Extended Info tab of the Institutional Provider
Information form (located in the Reference File Maintenance module). This "Requires POA
Reporting" field should be set to "Y" for providers that are required to submit POA information.
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Leave this field empty or set to "N" for providers that are exempt from POA reporting. The
value entered in this field for the claim's billing provider will control whether or not the edits
prompt for entry of POA information during claim entry.
Saving & Canceling Claims
After completing data entry on the claim form, click the "Save" button (or type "<ALT>S") to
save and exit the claim. Alternatively, click the "Cancel" button to abandon any changes and
exit the claim. When an attempt is made to save a claim, the following occurs:
Submission Payer Determination - At least one of the payers specified on a claim
must have the same LOB (line-of-business) as the claim itself. You will not be allowed to
save a claim unless this condition is met. If only one of the claim payers has a LOB that
matches the claim LOB, then this payer is automatically designated as the "submission"
payer -- the payer to which the claim is to be submitted. If you view the claim after
saving, you will see a checkmark adjacent to the submission payer line on the Payer
Information tab. It is possible that multiple payers on a claim will have an LOB that
matches the claim's LOB. In this case, you will be prompted to select which of these
payers is to be designated as the submission payer.
Edit Validation - During the claim save process, an edit validation process is performed
on all fields on the claim. This process includes re-evaluating all "field-level" edits (as
defined above). In addition, all claim "file-level" edits are evaluated. File-level edits are
evaluated only when the claim is saved, and are typically those edits that require multiple
data elements from the claim in order to be evaluated. If no edit validation errors occur,
the claim is saved with a "clean" (CLN) status. If, however, one or more edit validation
errors occur, you will be presented with the Edit Validation Errors List form (unless
disabled in the Preference settings). This form lists all the edit validation errors that have
occurred, indicating which ones are "fatal" and which are "non-fatal". Refer to the
"Claim & Reference File Edit Validation" topic for a more complete discussion of the
claim edit validation process and the Edit Validation Errors List form. If edit errors exist,
you will usually have the option to correct the errors or save the claim with errors. If a
fatal error exists on the "LOB", "PCN", or "TOB" field, however, you must correct the
error before saving the claim. Click the "Save With Errors" button to save a claim that
contains only non-fatal errors. Such claims are assigned the "has errors" (ERR) status.
Click the "Save With Fatal" button to save a claim that contains fatal errors. Such claims
are assigned the "has fatal errors" (ERF) status. Claims with an "ERF" status will not be
eligible for preparation into an electronic (EMC) file.
If edit validation errors occur, several "Save" attempts may be required to correct and save a
"clean" claim. At any time, click the "Errors List" button to review the remaining edit validation
errors.
Miscellaneous Claim Form Topics
The following comments cover a few miscellaneous features of the Institutional Claim Form:
Entering Form Locator Data - In order to preserve space on the Institutional Claim
Form, most of the fields that permit free-form text entry have been implemented as popup windows. These fields are activated by clicking the associated button (e.g., the "FL1"
button at the top of the Patient Info & Codes tab activates the "Form Locator 1" popup
window. Simply enter the text in this pop-up window - pressing the "ENTER" key to start
a new line if desired - and press the "TAB" key to exit and close the window.
Viewing Home Health Plans of Care - Type "<ALT>H" to display a list of Home Health
Plans of Care (Form No. CMS-485 / CMS-486) on file for the patient specified in the
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claim. The plan information cannot be modified from this list. Refer to the "Listing,
modifying and maintaining Plans of Care" topic for details on how plans can be added or
updated.
Displaying Audit information - Click the picture button in the upper right corner of the
Patient Info & Codes tab to display audit information for this claim. This audit information
includes the date the claim was created, the last modification date, and the User ID of
the user that modified the claim last.
Common Claim Activities
The following hyperlinks provide additional instruction on several common claim activities:
Refer to the "Adding a new claim" topic for more information on adding claims.
Refer to the "Listing, modifying and maintaining claims" topic for tips on maintaining claims
from the Institutional Claim List form.
Refer to the "Printing claims" topic to learn about printing claims.
Refer to the "Posting claim payments (Institutional)" topic to learn about Institutional claim
payment posting.
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The Professional Claim Form
The Professional Claim Form provides access to all data elements of an Professional claim.
New claims are entered and existing claims are viewed and/or modified from this form. The
Professional Claim Form has been designed to provide a data entry flow resembling that of the
printed Professional claim form whenever possible. Claim fields are grouped logically on six
major tabs:
Patient Info & General - includes fields for general claim and patient information.
Insured Information - includes payer, insured, and employer fields for the primary,
secondary, and tertiary payers.
Billing Line Items - includes the claim diagnosis codes as well as all claim line item
fields, extended line item fields, claim attachment fields, and line-level MSP/COB fields.
This major tab contains a number of second-level tabs to accommodate the many linelevel fields.
Ext. Patient/General - includes patient legal representative fields, facility information
fields, and numerous general claim fields that are not present on the hard-copy
Professional claim form.
Ext. Pat/Gen (2) - includes additional claim-level information not present on the hardcopy Professional claim form. Additional diagnosis codes and claim-level supporting
providers are located on this tab. Most of the fields on this tab populate data elements
defined only for the ANSI-837 EMC format.
Ext. Payer/Insured - includes payer-level reference identifiers as well as less frequently
used payer, and insured fields for the primary, secondary, and tertiary payers. Also
includes fields for Medicare Secondary Payer (MSP) and other secondary claims where
Coordination of Benefits (COB) information is required. This major tab consists of a
number of second-level tabs that provide access to this extended information in a logical
and efficient manner.
Click the appropriate tab or simply press the "PAGE UP" and " PAGE DOWN" keys to move
between these major claim form sections. Holding down the "SHIFT" key while pressing the
"PAGE UP" and "PAGE DOWN" keys will cycle between second-level tabs, where applicable.
Entering Claim Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Use the "UP ARROW" and
"DOWN ARROW" keys to move up and down through the claim form fields, respectively.
A number of productivity enhancing features are available during claim data entry:
Fixed-List Lookups - The claim entry form supports fixed-list lookups on many of the
claim's fields. Fixed-list lookups apply to fields whose list of valid values can be
determined in advance. For example, "Patient Sex" typically has 3 possible values: "M"
(male), "F" (female), and "U" (unknown).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the claim form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The claim entry form supports variable-list lookups on a
number of the claim's fields. Variable-list lookups apply primarily to fields whose values
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are selected from reference files. Most variable-list lookups use other claim field values
(the specified claim "LOB", for example) to filter the presented list. For example, provider
lookups attempt to present only those provider records applicable to the claim being
entered. In addition, variable-list lookups often retrieve data used to fill in other claim
form fields. For example, selection of a Patient from the variable-list lookup completes
numerous patient-related fields on the claim. Access variable list lookups using the same
method described above for fixed-list lookups.
Recurring Field Sets - Field "sets" consist of two or more logically-related fields. For
example, most ANSI/X12 reference identifiers include an identification number, a type
code (qualifier), and in some situation a payer identifier as well. It is often a requirement
to support a variable number of occurrences of a particular field set. The claim entry form
provides an intelligent combo (i.e., dropdown) control to allow entry and maintenance of
such recurring field sets.
To identify a recurring field set, look for the
selector which will be positioned adjacent
to the rightmost field in the set. The recurring field set and associated selector function in
the following manner:
As the user tabs normally away from the last field in the set, the focus will
automatically return to the first field in the set and the next data occurrence will be
displayed. Only when all occurrences have been displayed will the focus move to the
next field on the claim entry form. This behavior permits the user to view all
occurrences without using the mouse, and also provides an opportunity to enter new
data if desired.
Click the selector graphic to open the dropdown list and display all existing data
occurrences. A vertical scrollbar will appear as needed to permit access to all
occurrences. Select an entry from the list or press the "ESC" key (or click elsewhere
on the form) to close the dropdown list. The data values corresponding to the
selected entry will be displayed in the field set and are now available for editing as
needed.
To add a new occurrence to a field set, either tab through all existing occurrences
until an empty field set is displayed or simply select the "[Enter New ...]" item in the
dropdown list.
Press the "F7" key while positioned on any field in the set to delete the selected
occurrence. You will be prompted to confirm the deletion.
If the focus moves away from a recurring field set while an empty occurrence is
displayed, the field set will automatically display the data for the first occurrence, if
any, rather than leave the screen fields blank.
The edit validation process understands the recurring nature of these special field
sets, and will automatically reposition to the proper occurrence when displaying edit
validation errors.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most claim form fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
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Descriptive Field Hints - Most claim form fields have field hints that provide a brief
description of the field's purpose. These hints are often called "fly-over hints", since they
become visible when the mouse pointer moves over the specified field (without actually
selecting the field). This feature can be disabled in the general preferences settings if
desired.
Line Item Scrolling - The Billing Line Items tab displays 6 claim lines at a time. For
claims that contain more than 6 line items, the user may scroll through the claim line
items one line at a time or one page (i.e., 6 lines) at a time using the buttons provided
along the right edge of this tab.
Tip: You can also use the up/down arrow keys to move from line to line, scrolling
when appropriate. Type "<ALT><PAGE UP>" (press the "Page Up" key while
holding the "ALT" key down) or "<ALT><PAGE DOWN>" to scroll up/down through
all claim line items one page at a time.
Line Item Features - The following productivity features are available on the Billing Line
Items tab:
Current Line Tracking - The Billing Line Items tab contains a number of secondlevel tabs. The first second-level tab (Line Item Details) displays the claim diagnosis
codes as well as the basic line item fields available on the hard-copy Professional
claim form. The remaining second-level tabs are linked to the currently selected line
on the Line Item Details tab. As the cursor moves from one line to another on the
Line Item Details tab, the remaining second-level tabs will track the new current line.
This technique provides an efficient method of providing access to a large number of
data elements on a potentially large number of claim lines. Notice that the Extended
Details tab caption always reports the current line for reference.
Diagnosis Pointer (Field 24e) Syntax - The diagnosis pointer can point to as many
as four of the twelve possible claim diagnosis codes. For example, a diagnosis
pointer value of "1357" indicates that the service line references the first, third, fifth
and seventh diagnosis codes. No punctuation is necessary in the diagnosis pointer
when pointing only to combinations of the first nine diagnosis codes. However, when
pointing to the tenth, eleventh or twelfth diagnosis codes, each individual pointer
value in the diagnosis pointer must be separated by a comma. Examples of valid
diagnosis pointers are: "1234", "6789", "7,8,9,10" and "9,10,11,12". Use the values
"10,", "11," and "12," (notice trailing comma) to specify only the tenth, eleventh and
twelfth diagnosis code, respectively.
Line Duplication - Press the "F5" key while positioned on any field on a line to copy
the values in all fields of the previous line (except the service date fields) into the
current line. The service date fields in the current line are blanked and the cursor is
then positioned on the first field of the current line.
Field Duplication -- Press the "F4" key while positioned on a specific field on a line
to copy the value of that single field from the previous line into the current line.
Tip: You can also use the "F4" key to duplicate the service line "Narrative" text
from the previous line into the current line. This convenient feature eliminates the
need to re-type narrative text on consecutive service lines. The "Narrative" field is
located on the service line's Extended Details sub-tab.
Line Deletion - Press the "F7" key while positioned on any field on a line to delete
the line. You will be prompted to confirm the deletion. Alternatively, enter the value
"*DEL*" (that's an asterisk plus "DEL" plus another asterisk, without the doublequotes) into the Procedure Code field (24d) on a claim line to delete the line.
Advance To Next Line - Press the "F8" key while positioned on any field on a line to
automatically advance the cursor to the first field of the next line, skipping over any
remaining fields on the current line.
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Jump To Narrative - Press the "<ALT>N" key combination while positioned on any
field on a line to automatically position on the "Narrative" field. Enter the desired
narrative text and press the "<TAB>" key to return to the original line field.
Line Item Totals Recalculation – The Billing Line Items tab provides a "Recalculate"
button located near the bottom of the tab adjacent to the totals fields. Click this button to
recalculate and update the "Total Charge" and "Balance Due" fields from the current
claim line item charges values and the "Amount Paid" field value. NOTE: This button
may not be available on some installations.
Payer / Insured Features - The following payer and/or insured information productivity
features are available:
Quick Payer Access - Press the "<ALT>I" key combination while positioned
anywhere on the Patient Info & General tab to move immediately to the primary
payer's "Payer ID" field. Press the "<ALT>O" key combination to move immediately
to the secondary payer's "Payer ID" field.
Clear Payer Feature - The Insured Information tab provides a "Clear Payer" button
for each of the 3 claim payers. Click this button to clear all payer, insured and
employer fields for the associated payer.
Coordination of Benefits (COB) Support – The claim form includes fields to allow
entry of Coordination of Benefits (COB) data at both the claim and line levels when
appropriate. Enter a "Y" in the "COB?" field to make these COB-related fields available
for use. The "COB?" field is located along the lower edge of the Patient Info & General
tab. See the section entitled "Coordination of Benefits" later in this topic for details on
this advanced capability.
When the focus leaves a claim form field (either by pressing the "TAB" key or clicking on a
new field), an edit validation process is performed on the field losing the focus. Edits performed
at this time are referred to as "field-level" edits. If a field-level edit validation error occurs, you
will receive an audible response and the edit validation error message will be displayed in the
lower left corner of the claim form. In addition, the focus will remain on the field so that you can
correct the problem if desired. If you choose not to correct the data at this time, simply press
the "TAB" key again to move to the next field. Refer to the "Claim & Reference File Edit
Validation" topic for a more complete discussion of the claim edit validation process.
Claim Attachments
Claims submitted for certain types of professional services require supporting data that is not
included on the basic Professional claim. In the world of "paper" claims, this supporting data is
usually submitted on separate forms know as "attachments". PC-ACE Pro32 has extended
this attachment metaphor into the world of electronic claims submission. The Professional
Claim Form supports most of the commonly used attachment types.
Claim attachments can be "triggered" (activated) for a claim's line item in one of 2 ways:
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Automatically Triggered Attachments - Since the procedure (HCPCS) code on a claim's
line item describes the type of service provided, it is logical that this same procedure code
would dictate which attachment is required (if any) for the line. Using automatically
triggered attachments, certain procedure codes are pre-defined to trigger specific
attachment types. Automatically triggered claim attachments fall into one of 2 categories "line-level" attachments and "claim-level" attachments. Line-level attachments are
defined separately for each service line item on the claim that triggers the attachment. If
the procedure codes for 3 line items all trigger a certain line-level attachment, then the
user will be required to enter a separate set of attachment data for each of the 3 lines.
Claim-level attachments, on the other hand, are defined only once for the entire claim
regardless of how many service line items have triggered the attachment. The
Professional Claim Form supports both types of automatically triggered attachments.
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Note: The decisions regarding which procedure codes should automatically trigger
which attachments are typically made by the distributor (or whoever makes your
claim submission rules). PC-ACE Pro32 supports an external attachment trigger
control file to provide flexibility in this area. On program startup, PC-ACE Pro32
reads the trigger control file and uses this information to present the appropriate
attachment at the appropriate time.
Manually Triggered Attachments - To provide maximum flexibility, PC-ACE Pro32 also
allows the user to "manually" trigger a specific claim attachment on any claim line item.
Simply enter the appropriate attachment trigger code in the desired claim line item's
"AT" control. For convenience, you may press the "F2" key or right-click the mouse while
focused on the "AT" control to display a popup selection menu. All manually triggered
attachments are "line-level" by definition.
Tip: The special "Cancel automatic attachment" manual trigger code is available to
override (cancel) any automatically triggered claim line item attachment. This
override is useful in exception situations where it is desirable not to send a typically
required claim attachment.
Note: The manual attachment trigger feature may not be available in all installations.
If the claim line item's "AT" control is disabled and will not allow entry of the
attachment trigger code, then this feature is unavailable.
Attachments are displayed on second-level tabs on the Billing Line Items tab. These
attachment tabs are shown or hidden dynamically based on the currently selected service line
and the attachment type (line-level or claim-level). If the procedure code on the current line
automatically triggers a particular attachment, or if an attachment is manually triggered, then
the corresponding attachment tab will be shown. Since claim-level attachments exist only once
for the entire claim, the associated attachment tabs are visible regardless of the current line
position. Claim-level attachments are identified by a "(C)" designator on the attachment tab's
caption.
The following attachment productivity features are also available:
CLIA and Mammography Certification Numbers – When a CLIA or Mammography
attachment is triggered, the corresponding certification number is retrieved from the
claim's billing (solo) or rendering (group) provider reference file record if available. These
certification numbers can be setup in advance in the Professional Provider reference file,
thus freeing the user from remembering and entering these numbers on each claim
attachment.
Attachment Field Duplication - Press the "F5" key while positioned on any line-level
attachment field to copy all attachment field values from the closest previous line with the
same attachment type into the current line's attachment fields. This feature minimizes
the need to type line-level attachment data multiple times on a single claim.
Coordination of Benefits
The Professional Claim Form includes fields to allow entry of Coordination of Benefits (COB)
information at the claim and/or line level. Claims submitted to secondary or tertiary payers may
be required to report the payment remittance data returned by prior payers. Medicare
Secondary Payer (MSP) claims, for example, must include specific COB information obtained
from the primary payer in order to insure prompt processing by Medicare.
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Note: Since Coordination of Benefits information is not required on all claims, the
screen tabs containing COB-related fields are hidden by default. Enter a "Y" in the
"COB?" field to make these COB-related fields available for use. The "COB?" field is
located along the lower edge of the Patient Info & General tab.
Two distinct levels of Coordination of Benefits reporting are supported:
Claim-Level COB Reporting – Remittance data which is not specific to a particular
service line is reported at the claim level. The claim form provides claim-level COB fields
for both the primary and secondary payers. These fields are located on the "COB Info
(Primary) and "COB Info (Secondary)" sub-tabs of the Extended Payer/Insured tab.
Line-Level COB Reporting – Remittance data specific to a particular service line is
reported at the line level. The claim form provides a set of line-level COB fields for each
service line. These fields are located on the "MSP/COB" sub-tab of the Billing Line Items
tab. This sub-tab tracks the currently selected service line in the same manner as the
other extended line item sub-tabs. The current service line is identified in the
"MSP/COB" sub-tab caption (e.g., "MSP/COB (Line 4)").
The decision to report COB information at the claim versus line level is made by the payer and
communicated to the provider via a remittance. The remittance may be in electronic (ANSI835) or paper format, and typically serves as the source for all COB data to be entered into the
claim form's COB fields.
Tip: There's no need to re-enter claims for submission to secondary payers if the
original claim was processed through PC-ACE Pro32. Simply use the Professional
Claim List form to locate the original claim in the "TR – transmitted" location, select the
"Copy" action to create the new secondary claim, and enter the LOB and Billing
Provider applicable to the secondary payer. Finally, enter a "Y" in the "COB?" field on
the Patient Info & General tab to activate the COB-related fields. You will then have a
duplicate of the original claim ready to add the primary payer's COB information.
The claim-level COB data is entered on the "COB Info (Primary)" and "COB Info
(Secondary)" sub-tabs of the Extended Payer/Insured tab. The purpose and use of the
various field groups on these sub-tabs are as follows:
Claim-Level Adjustments (CAS) – Permits entry of one or more claim-level
adjustments as reported by the payer. Adjustments are defined by a specific "Group"
code and "Reason" code combination. Enter these codes manually or select them from
the available lookup lists. Each claim-level adjustment must specify a non-zero "Amount"
value and may also specify an optional "Units" value.
COB / MOA Amounts – Permits entry of various general claim-level COB amount
values as well as amount values defined specifically for Medicare Outpatient
Adjudication (MOA) use. Enter or select the "Code" which defines the amount type to be
reported, and enter the corresponding "Amount" value.
Medicare Outpatient Adjudication (MOA) Remarks Codes – Permits entry of up to 5
remarks codes for Medicare Outpatient Adjudication (MOA) use. These optional codes
may be entered manually or selected from the available lookup list.
Claim Adjudication Date – Permits entry of the date on which the payer adjudicated the
claim. This date is typically required at either the claim or line level.
Common Payer MSP Information – Contains miscellaneous COB-related fields which
are either defined in the ANSI / X12 implementation or are needed to support COB
editing.
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The line-level COB data is entered on the "MSP/COB" sub-tab of the Billing Line Items tab.
The purpose and use of the various field groups on this sub-tab are as follows:
Service Line Adjudication (SVD) Information – Permits entry of one or more Service
Line Adjudication (SVD) lines as reported by the payer for the current service line. The
"P/S" field identifies the payer (primary/secondary) reporting this line adjudication notice.
The procedure code and modifier fields identify the specific procedure being adjusted.
The practice of procedure code "bundling" and "unbundling" utilizes these fields to
provide specific information regarding how the payer has grouped the procedures for
payment. The "Paid Amount" indicates the amount the payer has paid on this procedure.
The "Paid Units" value permits reporting of payments for less than the originally billed
units. Finally, the "B/U Line" field identifies the service line on the original claim to which
this SVD line applies. This reference identifier should be included on the remittance, and
is primarily used in scenarios where procedure code bundling/unbundling has occurred.
Line Adjustment (CAS) & Miscellaneous Adjudication Info – Permits entry of several
additional Service Line Adjudication (SVD) fields for the current SVD line. The fields in
this control group track the currently selected SVD line. The control group's caption
indicates the current SVD line (e.g., "(for SVD 1 above)").
Line-Level Adjustments (CAS) – Permits entry of one or more line-level
adjustments as reported by the payer for the current Service Line Adjudication
(SVD) line. Adjustments are defined by a specific "Group" code and "Reason" code
combination. Enter these codes manually or select them from the available lookup
lists. Each line-level adjustment must specify a non-zero "Amount" value and may
also specify an optional "Units" value.
Common Line MSP Information – Contains miscellaneous line-level COB-related fields
defined in the ANSI / X12 implementation.
Tip: Fixed-list or variable-list lookups are available on many of the COB-related
fields to improve user efficiency. In addition, the standard line duplication (F5), field
duplication (F4), and line deletion (F7) functions are available on all COB-related
scrolling arrays. As an additional convenience, pressing the "F5" key while
positioned on the first Service Line Adjudication (SVD) line will populate the SVD
fields with their equivalent values from the original service line.
Saving & Canceling Claims
After completing data entry on the claim form, click the "Save" button (or type "<ALT>S") to
save and exit the claim. Alternatively, click the "Cancel" button to abandon any changes and
exit the claim. When an attempt is made to save a claim, the following occurs:
Submission Payer Determination - At least one of the payers specified on a claim
must have the same LOB (line-of-business) as the claim itself. You will not be allowed to
save a claim unless this condition is met. If only one of the claim payers has a LOB that
matches the claim LOB, then this payer is automatically designated as the "submission"
payer -- the payer to which the claim is to be submitted. If you view the claim after
saving, you will see a checkmark adjacent to the submission payer line on the Payer
Information tab. It is possible that multiple payers on a claim will have a LOB that
matches the claim's LOB. In this case, you will be prompted to select which of these
payers is to be designated as the submission payer.
Edit Validation - During the claim save process, an edit validation process is performed
on all fields on the claim. This process includes re-evaluating all "field-level" edits (as
defined above). In addition, all claim "file-level" edits are evaluated. File-level edits are
evaluated only when the claim is saved, and are typically those edits that require multiple
data elements from the claim in order to be evaluated. If no edit validation errors occur,
the claim is saved with a "clean" (CLN) status. If, however, one or more edit validation
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errors occur, you will be presented with the Edit Validation Errors List form (unless
disabled in the Preference settings). This form lists all the edit validation errors that have
occurred, indicating which ones are "fatal" and which are "non-fatal". Refer to the
"Claim & Reference File Edit Validation" topic for a more complete discussion of the
claim edit validation process and the Edit Validation Errors List form. If edit errors exist,
you will usually have the option to correct the errors or save the claim with errors. If a
fatal error exists on the "LOB" or "PCN" field, however, you must correct the error before
saving the claim. Click the "Save With Errors" button to save a claim that contains only
non-fatal errors. Such claims are assigned the "has errors" (ERR) status. Click the "Save
With Fatal" button to save a claim that contains fatal errors. Such claims are assigned
the "has fatal errors" (ERF) status. Claims with an "ERF" status will not be eligible for
preparation into an electronic (EMC) file.
If edit validation errors occur, several "Save" attempts may be required to correct and save a
"clean" claim. At any time, click the "Errors List" button to review the remaining edit validation
errors.
Miscellaneous Claim Form Topics
The following comments cover a few miscellaneous features of the Professional Claim Form:
Optional Local Fields - Your distributor may have configured additional "local" fields at
the claim, payer, and/or line item levels. Local fields are typically defined to provide data
elements that are needed by the distributor but are not included in the Professional
specification. If such local fields are defined at the claim level, you will see an additional
"Local Fields" tab on the claim form. If local fields are defined at the payer and line item
levels, you will see similar "Local Fields" second-level tabs on the Extended
Payer/Insured tab and Billing Line Items tab, respectively.
Displaying Audit information - Click the picture button in the upper right corner of the
Patient Info & General tab to display audit information for this claim. This audit
information includes the date the claim was created, the last modification date, and the
User ID of the user that modified the claim last.
Common Claim Activities
The following hyperlinks provide additional instruction on several common claim activities:
Refer to the "Adding a new claim" topic for more information on adding claims.
Refer to the "Listing, modifying and maintaining claims" topic for tips on maintaining claims
from the Professional Claim List form.
Refer to the "Printing claims" topic to learn about printing claims.
Refer to the "Posting claim payments (Professional)" topic to learn about Professional
claim payment posting.
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Eligibility Benefit Request List Form Features
The PC-ACE Pro32 Eligibility Benefit Request List form provides a versatile interface from
which the user can create, list, modify and otherwise maintain patient eligibility benefit
requests. Click either the "Institutional Claims Processing" button or "Professional Claims
Processing" button on the PC-ACE Pro32 Main Toolbar to open the corresponding Claims
Menu form. Then click the "Maintain Eligibility Benefit Requests" item on the Claims Menu
form's "Maintain" menu to open the Eligibility Benefit Request List form. You may reposition
and resize this form if desired. The list can be easily sorted and filtered to display only the
requests of interest. The Institutional and Professional Eligibility Benefit Request List forms are
virtually identical. All procedures described in this section pertain to both request types unless
otherwise specified.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Maintain Eligibility Benefit Requests" item is not visible on the
"Maintain" menu, then this capability is not available on your installation.
Sorting Eligibility Benefit Requests
The eligibility benefit request list may be sorted by Patient Name, Patient Control Number
(PCN), Entry Date and Submit Date. Simply select the desired sort order from the available
"Sort By" radio buttons.
Filtering Eligibility Benefit Requests
The eligibility benefit request list may be filtered to display a select subset of requests by
manipulating the "Eligibility Request List Filter Options" drop-down lists. Basic filter options
include:
Location - filters the eligibility benefit request list to include only requests in the "to be
submitted" (EL) or "transmitted" (TR) locations.
Status - filters the eligibility benefit request list to include only requests assigned a
specific status. The possible status codes are: "clean/ready" (CLN), "has fatal errors"
(ERF), "has errors" (ERR), "held" (HLD) and "unprocessed" (UNP).
LOB - filters the eligibility benefit request list to include only requests for a specific line of
business.
In addition to these basic filter options, the Eligibility Benefit Request List form also provides a
number of Advanced Filter Options. These advanced options permit filtering on the request's
patient, payer, entry date range, submission date range, and numerous other criteria. When
multiple filter criteria are specified, only those requests that meet all filter criteria will be
displayed.
Eligibility Benefit Request Actions
The Eligibility Benefit Request List form may also be used to perform specific actions on any
individual request or a group of selected requests. To perform an action on an individual
request, simply select the request from the list and click the desired action button (along the
lower edge of the form). The complete list of request actions can be accessed from the
Eligibility Benefit Request List form's main "Actions" menu or from the convenient pop-up
menu (accessed by right clicking the mouse over the selected request). Available eligibility
benefit request actions include:
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Creating New Requests -- Click the "New" button (or choose the "Create New
Request", "Create New Request (Service Type)" or "Create New Request
(Complete)" action) to create a new eligibility benefit request. See the "Adding a new
eligibility benefit request" topic for more details.
Note: The "Create New Request (Service Type)" action may not be available on all
installations. When this action is unavailable, all new requests should be initiated
by clicking the "New" button or selecting the "Create New Request" action.
Viewing/Modifying Requests -- Click the "View/Update" button (or choose the
"View/Update Selected Request" action) to view and/or modify the selected eligibility
benefit request. See the "Eligibility Benefit Request Form" topic for details on using the
PC-ACE Pro32 eligibility benefit request entry form.
Tip: The View/Update action is the default eligibility benefit request action. In
addition to the techniques described above, this action can also be invoked by
double-clicking on the desired request record or by selecting the desired record
and pressing the "ENTER" key.
Tip: Holding down the "SHIFT" key while invoking the View/Update action on an
eligible eligibility benefit request will force an automatic save attempt on the
request. This is a shortcut technique equivalent to invoking the View/Update action
and subsequently clicking the "Save" button on the request entry form. It minimizes
the keystrokes required to work requests from the Eligibility Benefit Request List
form. Eligible requests are those in the "to be submitted" (EL) location with a status
of either "unprocessed" (UNP), "has errors" (ERR), or "has fatal errors" (ERF).
Deleting Requests -- Click the "Delete" button (or choose the "Delete Selected
Request" action) to delete the selected eligibility benefit request.
Attention: Deleted eligibility benefit requests are permanently removed from
PC-ACE Pro32 … they cannot be recovered.
Copying Requests -- Click the "Copy" button (or choose the "Copy Selected Request"
action) to copy the selected eligibility benefit request. The eligibility benefit request entry
form will be displayed containing the details of the newly copied request.
Holding Requests -- Choose the "Hold Selected Request" action to change the status
of the selected eligibility benefit request to "held" (HLD). Held requests are not eligible
for preparation.
Releasing Requests -- Choose the "Release Selected Request" action to release a
previously held eligibility benefit request. In addition to releasing the request, this action
also sets the status of the selected request to "unprocessed" (UNP).
Reactivating Requests -- Choose the "Reactivate Selected Request" action to
reactivate the selected eligibility benefit request. This action will move the previously
submitted request from the "submitted" (TR) location into the "to be submitted" (EL)
location. The reactivated request will be assigned the "unprocessed" (UNP) status.
Viewing Responses -- Choose the "View Response for Selected Request" action to
view the ANSI-271 eligibility benefit response information for the selected eligibility
benefit request. Refer to the "Viewing the eligibility benefit response for a specific
request" topic for additional information.
Note: This action is available only when the Eligibility Benefit Request List is
filtered to view requests in the "submitted" (TR) location. The "Reply?" column will
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contain the value "Yes" when a response has been received and posted for the
selected eligibility benefit request.
Refreshing the Request List -- Choose the "Refresh Request List" action (or press
the "F5" function key) to refresh the current Eligibility Benefit Request List form contents.
This action can be useful in a multi-user installation to be sure that the request list
properly reflects additions and/or modifications made by other users.
Note: You will notice that only applicable actions are enabled for use in the main
"Actions" menu or pop-up menu. For example, it makes no sense to "reactivate" an
eligibility benefit request that has yet to be submitted, so this action will be disabled for
requests in the "to be submitted" (EL) location.
Actions on Multiple Eligibility Benefit Requests
Some actions can be performed on multiple eligibility benefit requests at once. Multiple request
selection is accomplished by "checking" the request of interest and subsequently performing
one of the "… All Checked Requests" actions. To check a request, click the left mouse button
over the checkbox in the first column of the desired list row. Alternatively, all requests in the
current list can be checked using the "Check All Requests" item from the list's pop-up menu.
Use the flexible Eligibility Benefit Request List form filter techniques to display only the subset
of requests to be deleted, held, reactivated, etc. Then simply check all eligibility benefit
requests and perform the desired action on all checked requests at once.
Eligibility Benefit Request List Filter Menu
Several eligibility benefit request list filtering and related functions are accessible from the
Eligibility Benefit Request List form’s main "Filter" menu:
Clear Filters – Clears any existing filter criteria and refreshes the eligibility benefit
request list to display all requests in the selected location.
Advanced Filter Options – Opens the Advanced Eligibility Request List Filter Criteria
form to permit filtering on the request's patient, payer, entry date range, submission date
range and numerous other criteria. When multiple filter criteria are specified, only those
requests that meet all filter criteria will be displayed.
Check (Uncheck) All Requests – Permits the user to "check" (or "uncheck") all
eligibility benefit requests currently displayed in the request list – presumably in
anticipation of some action to be performed on this block of requests. See the "Actions
on Multiple Eligibility Benefit Requests" section above for more information.
Eligibility Benefit Request Preferences
Certain aspects of the Eligibility Benefit Request Form operation are customizable. The default
behavior is typically determined by your software distributor, so you should check with their
support department before making changes to these settings. The Eligibility Benefit Request
Preferences are accessible from the Eligibility Benefit Request List form’s main "File" menu
"Preferences" item. The following options are available for configuration:
General Eligibility Benefit Preferences – Select the "General" tab to view and/or modify
general eligibility/benefit preferences:
Default Information Source Type to Payer (Code = 'PR') - This option controls the
default value assigned to the Information Source Type field for new requests.
When checked, the Information Source Type is defaulted to the "Payer" code (PR).
Most distributors expect a payer to be identified in the Information Source fields.
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Setting this field to "PR" enables Information Source lookups from the Payer
reference file.
When unchecked, the Information Source Type field is left empty and must be
entered by the user (or selected from the right-click popup menu).
Default Information Source Primary Identification Type to NAIC (Code = 'NI') This option controls the default value assigned to the Information Source Primary
Identification Type field for new requests. It is available only when the Information
Source Type is being defaulted to the "Payer" code (PR).
When checked, the Information Source Primary Identification Type will be
defaulted to the "NAIC" code (NI) during Information Source lookups from the
Payer reference file.
When unchecked, the Information Source Primary Identification Type will be
defaulted to the "Payer Identification" code (PI) during Information Source
lookups from the Payer reference file.
Default Information Receiver Type to Provider (Qualifier = '1P') - This option controls
the default value assigned to the Information Receiver Type field for new requests.
When checked, the Information Receiver Type is defaulted to the "Provider" code
(1P). Most distributors expect a provider to be identified in the Information Receiver
fields. Setting this field to "1P" enables Information Receiver lookups from the
Provider reference file.
When unchecked, the Information Receiver Type field is left empty and must be
entered by the user (or selected from the right-click popup menu).
Load Information Receiver Primary ID with Federal Tax ID on Provider lookups - This
option controls the source for the value assigned to the Information Receiver Primary ID /
Type fields during lookups from the Provider reference file.
When checked, the Information Receiver Primary ID / Type fields are populated with
the Federal Tax ID / Type fields from the selected Provider record.
When unchecked, the Information Receiver Primary ID / Type fields are populated
with the standard Provider ID/No. / Type fields from the selected Provider record.
Default Tax ID Type to generic code 'FI' instead of '24' (EIN) or '34' (SSN) - This
option controls the source for the value assigned to the Information Receiver Primary
ID Type field during lookups from the Provider reference file. This option is only
available when the Federal Tax ID has been selected to populate the Information
Receiver Primary ID field.
When checked, the Information Receiver Primary ID Type field is forced to the
generic Tax ID type code (FI).
When unchecked, the Information Receiver Primary ID Type field is populated
with the ANSI/X12 qualifier corresponding to the Federal Tax ID Type value
from the selected Provider record. Valid qualifier values are "24" (EIN) and "34"
(SSN).
Give preference to non-person Organization name on Information Receiver lookups
- This option controls the preferred source for the value assigned to the Information
Receiver Name fields during lookups from the Provider reference file.
When checked, the Information Receiver Name fields are populated with the nonperson "Organization" field from the selected Provider record, if available. If no
organization is specified on the selected Provider record, then the proper (i.e.,
person) name fields are used instead.
When unchecked, the Information Receiver Name fields are populated with the
proper (i.e., person) name fields from the selected Provider record, if available. If no
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proper name is specified on the selected Provider record, then the value in the
"Organization" field is used instead.
Simplified Service Type Request Form Preferences – Select the "Service Type" tab
to view and/or modify Service Type Eligibility Benefit Request Form preferences:
Note: The simplified Service Type Eligibility Benefit Request Form may not be available
on all installations. If you do not see the "Service Type" preferences tab, then this
feature is unavailable.
Use the simplified Service Type request form by default for new eligibility benefit
requests - This option controls which of the two available eligibility/benefit request forms
to display when the user clicks the "New" button on the Eligibility Benefit Request List
Form.
When checked, the simplified Service Type Eligibility Benefit Request Form will be
displayed when the user clicks the "New" button on the Eligibility Benefit Request
List Form.
When unchecked, the complete Eligibility Benefit Request Form will be displayed
when the user clicks the "New" button on the Eligibility Benefit Request List Form.
Tip: New eligibility/benefit requests may be added using either request form by
selecting the desired "Create New Request …" item from the Eligibility Benefit
Request List form's main "Actions" menu.
Payer Selection List - This list box holds the payers that will be available for selection on
the simplified Service Type Eligibility Benefit Request Form. If visible, click the "Add"
button to choose a payer from the Payer reference file and add this payer to the selection
list. Select an existing payer in the list and click the "Remove" button to remove this payer
from the selection list. Use the "Up Arrow" and "Down Arrow" picture buttons to
rearrange the order of payers in the selection list. The first payer in the selection list will be
the default payer when creating new Service Type eligibility benefit requests.
Note: PC-ACE Pro32 distributors have the option to pre-configure and restrict this
default eligibility/benefit payer selection list. The "Add", "Remove", "Up Arrow", and
"Down Arrow" buttons will not be visible when this restriction has been imposed by
the distributor.
Allow selection from Payer reference file - This option controls whether or not users
will be allowed to select payers other than those in the Payer Selection List when
creating new Service Type eligibility/benefit requests.
When checked, selection of alternate payers from the Payer reference file will
be allowed. The payer dropdown list on the Service Type Eligibility Benefit
Request Form will include a special "<< Select From Payer Reference File >>"
item to initiate the Payer file selection process.
When unchecked, only payers included in the Payer Selection List will be
available for selection when creating new Service Type eligibility/benefit
requests.
Provider Selection List - This list box holds the providers that will be available for
selection on the simplified Service Type Eligibility Benefit Request Form. Users should
add commonly used providers to this list in order to streamline the process of creating new
Service Type eligibility/benefit requests. Click the "Add" button to choose a provider from
the Institutional or Professional Provider reference file and add this provider to the
selection list. Select an existing provider in the list and click the "Remove" button to
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remove this provider from the selection list. Use the "Up Arrow" and "Down Arrow"
picture buttons to rearrange the order of providers in the selection list. The first provider in
the selection list for a given LOB and Payer ID combination will become the default
provider when creating new Service Type eligibility benefit requests for that payer.
Note: In addition to the providers listed in the Provider Selection List, users will also
be allowed to select from the complete Institutional or Professional Provider
reference files when creating new Service Type eligibility/benefit requests. The
provider dropdown list on the Service Type Eligibility Benefit Request Form will
include a special "<< Select From Provider Reference File >>" item to initiate this
Provider file selection process.
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The Eligibility Benefit Request Form
The Eligibility Benefit Request Form provides access to all data elements defined in the ANSI270 Health Care Eligibility Benefit Inquiry transaction. New requests are entered and existing
requests are viewed and/or modified from this form. Request fields are grouped logically on
these major tabs:
Patient/Subscriber Info - includes fields for patient and subscriber name, address,
relationship, and demographic information.
Eligibility/Benefit Inquiry - includes fields describing the eligibility benefit information
being requested – from general coverage information to detailed coverage for specific
diagnoses and procedures.
Source/Receiver Info - includes fields defining the Information Source (Payer, typically)
and the Information Receiver (Provider, typically) associated with this request.
Patient/Subscriber Extended - includes less frequently used patient and subscriber
fields (e.g., additional identification numbers).
Receiver Extended - includes less frequently used Information Receiver fields such as
additional identification numbers and the provider's Taxonomy code.
Click the appropriate tab or simply press the "PAGE UP" and "PAGE DOWN" keys to move
between these major eligibility benefit request form sections.
Entering Eligibility Benefit Request Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Use the "UP ARROW" and
"DOWN ARROW" keys to move up and down through the eligibility benefit request form fields,
respectively.
A number of productivity enhancing features are available during eligibility benefit request data
entry:
Fixed-List Lookups - The eligibility benefit request entry form supports fixed-list lookups
on many of the request's fields. Fixed-list lookups apply to fields whose list of valid
values can be determined in advance. For example, the "Patient Sex" field has only two
possible values: "M" (male) and "F" (female).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the request form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The eligibility benefit request entry form supports variable-list
lookups on a number of the request's fields. Variable-list lookups apply primarily to fields
whose values are selected from reference files. Most variable-list lookups use other
eligibility benefit request field values (the specified request "LOB", for example) to filter
the presented list. For example, provider lookups attempt to present only those provider
records applicable to the request being entered. In addition, variable-list lookups often
retrieve data used to fill in other request form fields. For example, selection of a Patient
from the variable-list lookup completes numerous patient-related and subscriber-related
fields on the request. Access variable list lookups using the same method described
above for fixed-list lookups.
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Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Intelligent Groups Tabs - The eligibility benefit request entry form contains one or more
field "groups". The Diagnosis & Facility Type Codes control array on the Eligibility/Benefit
Inquiry tab is an example of such a group. Fields in these groups are always completed
sequentially. Therefore, when a field in one of these groups is left empty, it can be
assumed that data entry in the group is complete. When the "TAB" key is pressed, the
remaining fields in that group will be skipped and the cursor will be positioned on the first
field in the tab sequence beyond the group fields.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most eligibility benefit
request form fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
Inquiry Line Item Scrolling - The Eligibility/Benefit Inquiry tab displays 4 inquiry lines at
a time. For requests that contain more than 4 line items, the user may scroll through the
inquiry line items one line at a time or one page (i.e., 4 lines) at a time using the buttons
provided along the right edge of this tab.
Tip: You can also use the up/down arrow keys to move from line to line, scrolling
when appropriate. Type "<ALT><PAGE UP>" (press the "Page Up" key while
holding the "ALT" key down) or "<ALT><PAGE DOWN>" to scroll up/down through
all inquiry line items one page at a time.
Inquiry Line Item Features - The following line-item productivity features are available
on the Eligibility/Benefit Inquiry tab:
Current Line Tracking - The Eligibility/Benefit Inquiry tab contains the "Additional
Eligibility/Benefit Information" control group. This control group is linked to the
currently selected inquiry line on this tab. As the cursor moves from one inquiry line
to another, the information displayed in the Additional Eligibility/Benefit Information
fields will track the new current inquiry line. Notice that the Additional
Eligibility/Benefit Information control group caption always reports the current inquiry
line for reference.
Line Duplication - Press the "F5" key while positioned on any field on an inquiry line
to copy the values in all fields of the previous line into the current line.
Field Duplication -- Press the "F4" key while positioned on a specific field on an
inquiry line to copy the value of that single field from the previous line into the current
line.
Line Deletion - Press the "F7" key while positioned on any field on an inquiry line to
delete the line. You will be prompted to confirm the deletion.
Advance To Next Line - Press the "F8" key while positioned on any field on an
inquiry line to automatically advance the cursor to the first field of the next line,
skipping over any remaining fields on the current line.
When the focus leaves a request form field (either by pressing the "TAB" key or clicking on a
new field), an edit validation process is performed on the field losing the focus. Edits performed
at this time are referred to as "field-level" edits. If a field-level edit validation error occurs, you
will receive an audible response and the edit validation error message will be displayed in the
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lower left corner of the eligibility benefit request form. In addition, the focus will remain on the
field so that you can correct the problem if desired. If you choose not to correct the data at this
time, simply press the "TAB" key again to move to the next field. Refer to the "Claim &
Reference File Edit Validation" topic for a more complete discussion of the edit validation
process.
Key Concepts Regarding Eligibility Benefit Requests
The design of the ANSI-270 Health Care Eligibility Benefit Inquiry transaction allows the
requestor to enter as little or as much information as desired to ensure a match by the source
organization who will be processing the request. Fields that are required by the ANSI-270
specifications are enforced by edits on the Eligibility Benefit Request Form. The process of
entering an eligibility benefit request can be greatly streamlined by effective use of the
available variable-list lookups.
Patient Lookup - Press the "<F2>" key (or right-click the mouse) while positioned on the
Patient PCN or Patient Last/First Name fields to select a patient from the Patient
reference file. All applicable information on file for the selected patient will be used to
populate the corresponding eligibility benefit request fields. This will include the Patient
General Information fields, the Subscriber General Information fields (if Insured info is
setup on the Patient record), the Information Source fields (uses the Insured Payer info),
and the Information Receiver fields (if the Provider is setup on the Patient record, or if
only one Provider record is available).
Note: If secondary and/or tertiary payer/insured information is present on the
selected Patient record, the program will prompt the user to choose which of these
payers is applicable to this eligibility benefit request. Only the information from the
selected payer/insured set will be used to populate the corresponding request
fields.
Information Source - The Information Source refers to the entity serving as the "source"
of the eligibility benefit information. This role is typically performed by the payer (e.g.,
Medicare, commercial insurance, etc), however, the ANSI-270 transaction also allows for
several entity types other than payer. The "Information Source Type" field specifies the
intended entity type, which is assumed to be "PR - Payer" when left empty. Press the
"<F2>" key (or right-click the mouse) while positioned on the Information Source ID or
Organization field to select a payer from the Payer reference file. All applicable
information on file for the selected payer will be used to populate the corresponding
eligibility benefit request fields. This lookup feature is only available when the Information
Source Type field is set to "PR" (or is left empty).
Note: The eligibility benefit request also requires that a line of business (LOB) be
specified. This represents the line of business for the Information Source (payer) to
whom the inquiry is being submitted, and is necessary to enforce prepare break
rules and to permit more specific editing of the Information Source/Receiver fields.
Information Receiver - The Information Receiver refers to the entity which is requesting
and will "receive" the eligibility benefit information. This role is typically performed by the
provider, however, the ANSI-270 transaction also allows for several other entity types.
The "Information Receiver Type" field specifies the intended entity type, which is
assumed to be "1P - Provider" when left empty. Press the "<F2>" key (or right-click the
mouse) while positioned on the Information Receiver ID or Organization field to select a
provider from the Institutional or Professional Provider reference file. All applicable
information on file for the selected provider will be used to populate the corresponding
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eligibility benefit request fields. This lookup feature is only available when the Information
Receiver Type field is set to "1P" (or is left empty).
Inquiry Service Lines - Each eligibility benefit request must include one or more
Eligibility Benefit Inquiry service lines. The simplest inquiry service line consists of
Service Type = 30 (general health care coverage inquiry) with the remaining service line
entries left empty. Inquiries can also be made for specific procedure (HCPCS) codes,
and can include a number of extended service line data elements if desired. The
Information Source will provide eligibility benefit response information consistent with the
level of detail requested, if available.
Tip: Type "<ALT>F2" (press the "F2" function key while holding down the "ALT" key) to
provide a visual indication of all fields that support lookups. Press the "ESC" key to turn
off the flashing indicator.
Saving & Canceling Eligibility Benefit Requests
After completing data entry on the eligibility benefit request form, click the "Save" button (or
type "<ALT>S") to save and exit the request. Alternatively, click the "Cancel" button to
abandon any changes and exit the request. When an attempt is made to save a request, the
following occurs:
Edit Validation - During the request save process, an edit validation process is
performed on all fields on the request. This process includes re-evaluating all "field-level"
edits (as defined above). In addition, all request "file-level" edits are evaluated. File-level
edits are evaluated only when the request is saved, and are typically those edits that
require multiple data elements from the request in order to be evaluated. If no edit
validation errors occur, the request is saved with a "clean" (CLN) status. If, however, one
or more edit validation errors occur, you will be presented with the Edit Validation Errors
List form (unless disabled in the Preference settings). This form lists all the edit
validation errors that have occurred, indicating which ones are "fatal" and which are
"non-fatal". Refer to the "Claim & Reference File Edit Validation" topic for a more
complete discussion of the claim edit validation process and the Edit Validation Errors
List form. If edit errors exist, you will have the option to correct the errors or save the
request with errors. Click the "Save With Errors" button to save a request that contains
only non-fatal errors. Such requests are assigned the "has errors" (ERR) status. Click
the "Save With Fatal" button to save a request that contains fatal errors. Such requests
are assigned the "has fatal errors" (ERF) status. Requests with an "ERF" status will not
be eligible for preparation.
If edit validation errors occur, several "Save" attempts may be required to correct and save a
"clean" eligibility benefit request. At any time, click the "Errors List" button to review the
remaining edit validation errors.
Miscellaneous Eligibility Benefit Request Form Topics
The following comments cover miscellaneous features of the Eligibility Benefit Request Form:
Displaying Audit information - Click the picture button in the upper right corner of the
Patient/Subscriber Info tab to display audit information for this eligibility benefit request.
This audit information includes the date the request was created, the last modification
date, and the User ID of the user that modified the request last.
Common Eligibility Benefit Request Activities
The following hyperlinks provide additional instruction on several common eligibility benefit
request activities:
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Refer to the "Adding a new eligibility benefit request" topic for more information on adding
eligibility benefit requests.
Refer to the "Listing, modifying and maintaining eligibility benefit requests" topic for tips on
maintaining eligibility benefit requests from the Eligibility Benefit Request List form.
Refer to the "Preparing eligibility benefit request files for transmission" topic to learn about
preparing eligibility benefit requests into an ANSI-270 format file for transmission.
Refer to the "Viewing and maintaining eligibility benefit response files" topic to learn about
handling ANSI-271 response files returned from the Information Source (Payer).
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The Service Type Eligibility Benefit Request Form
The Service Type Eligibility Benefit Request Form provides a simple user interface for creating
new "service type" patient eligibility/benefit requests. This form provides access to only the
most commonly used data elements defined in the ANSI-270 Health Care Eligibility Benefit
Inquiry transaction. Service type requests are used for general eligibility inquiries, and must
include one of the valid eligibility Service Type codes.
Note: The Service Type Eligibility Benefit Request Form cannot be used to make
eligibility inquiries for specific procedure codes. Use the complete Eligibility Benefit
Request Form for such detailed inquiries.
Entering Service Type Eligibility Benefit Request Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Drop-down "combo box"
controls permit selection from a list of available items. All other edit controls allow key entry of
the desired field's information.
A number of productivity enhancing features are available during service type eligibility benefit
request data entry:
Fixed-List Lookups - The service type eligibility benefit request entry form supports
fixed-list lookups on several of the request's fields. Fixed-list lookups apply to fields
whose list of valid values can be determined in advance. For example, the "Gender"
fields have only two possible values: "M" (male) and "F" (female).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the request form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The service type eligibility benefit request entry form supports
variable-list lookups on the Payer, Provider, and Eligibility Type fields. Variable-list
lookups apply primarily to fields whose values are selected from reference files or other
dynamically-changing sources. Some variable-list lookups use other service type
eligibility benefit request field values to filter the presented list. For example, provider
lookups present only those provider records applicable to the payer specified for the
request. It is therefore necessary to select a valid payer before selecting the desired
provider. To access the Payer, Provider, and Eligibility Type variable list lookups, click
the down-arrow button adjacent to the respective combo box.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most service type eligibility
benefit request form fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
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derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
When the focus leaves a request form field (either by pressing the "TAB" key or clicking on a
new field), an edit validation process is performed on the field losing the focus. Edits performed
at this time are referred to as "field-level" edits. If a field-level edit validation error occurs, you
will receive an audible response and the edit validation error message will be displayed in the
lower left corner of the eligibility benefit request form. In addition, the focus will remain on the
field so that you can correct the problem if desired. If you choose not to correct the data at this
time, simply press the "TAB" key again to move to the next field. Refer to the "Claim &
Reference File Edit Validation" topic for a more complete discussion of the edit validation
process.
Additional Service Type Eligibility Benefit Request Form Information
The design of the ANSI-270 Health Care Eligibility Benefit Inquiry transaction allows the
requestor to enter as little or as much information as desired to ensure a match by the source
organization who will be processing the request. The simplified Service Type Eligibility Benefit
Request Form targets only general eligibility/benefit requests. These simple "service type"
requests typically include only the subscriber and/or patient name, the Subscriber (Member)
ID, and a code specifying the service type for which general eligibility information is being
requested.
Tip: You may encounter situations where you need to enter a value for one of the ANSI270 data elements that isn't represented on this simplified Service Type Eligibility Benefit
Request Form. When this situation arises, consider creating the request with this
simplified form and then modifying the resulting request to add the additional data
element. This two-step process may still be quicker that entering the entire request on
the complete Eligibility Benefit Request Form.
Fields that are required by the ANSI-270 specifications are enforced by edits on the Service
Type Eligibility Benefit Request Form. Here are a few important details concerning the use of
this simplified request form.
Payer Selection - Click the down-arrow button adjacent to the "Payer" combo box to
select the payer to whom this eligibility/benefit request will be submitted. The drop-down
list will include the preferred payers previously configured on the Eligibility Benefit
Request Preferences form. See the "Eligibility Benefit Request Preferences" section of
the "Eligibility Benefit Request List Form Features" help topic for information on setting
up preferred payers.
Note: The drop-down Payer selection list may also include the special "<< Select
From Payer Reference File >>" item. Choosing this item allows the user to select
a payer from the complete Payer reference file. See the "Eligibility Benefit Request
Preferences" section of the "Eligibility Benefit Request List Form Features" help
topic for more information on this feature.
Provider Selection - Click the down-arrow button adjacent to the "Provider" combo box
to select the provider requesting this eligibility/benefit information. The drop-down list will
include the preferred providers previously configured on the Eligibility Benefit Request
Preferences form. See the "Eligibility Benefit Request Preferences" section of the
"Eligibility Benefit Request List Form Features" help topic for information on setting up
preferred providers.
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Note: The drop-down Provider selection list will only include providers applicable to
the selected payer. A valid payer must therefore be selected before selecting the
provider. This selection list will also include the special "<< Select From Provider
Reference File >>" item. Choosing this item allows the user to select a provider
from the Institutional or Professional Provider reference file. Again, the selection
list will be filtered to display only those providers applicable to the selected payer.
Eligibility Type Selection - Click the down-arrow button adjacent to the "Eligibility
Type" combo box to select the desired eligibility Service Type code. The list will default
to "30 – Health Benefit Plan Coverage", which is the most commonly requested code.
Patient's Relationship To Subscriber - Enter the ANSI/X12 qualifier which describes
the patient's relationship to the subscriber in the "Relationship" field. Alternatively, you
may press the "<F2>" key (or right-click the mouse) while positioned on this field to
select from a list of valid qualifiers. When the "18 – Self" relationship qualifier is entered,
the "Patient Information" control group will be disabled. Since by definition the patient
and subscriber are the same person in this scenario, it is only necessary to enter the
personal information once, in the Subscriber Information fields. All other relationship
codes will permit entry of both the subscriber and patient information, although it may not
be necessary to enter both in order to perform a successful eligibility/benefit inquiry.
Saving & Canceling Service Type Eligibility Benefit Requests
After completing data entry on the service type eligibility benefit request form, click the "Save"
button (or type "<ALT>S") to save and exit the request. Alternatively, click the "Cancel" button
to abandon any changes and exit the request. When an attempt is made to save a request, the
following occurs:
Edit Validation - During the request save process, an edit validation process is
performed on all fields on the request. This process includes re-evaluating all "field-level"
edits (as defined above). In addition, all request "file-level" edits are evaluated. File-level
edits are evaluated only when the request is saved, and are typically those edits that
require multiple data elements from the request in order to be evaluated. If no edit
validation errors occur, the request is saved with a "clean" (CLN) status. If, however, one
or more edit validation errors occur, you will be presented with the Edit Validation Errors
List form (unless disabled in the Preference settings). This form lists all the edit
validation errors that have occurred, indicating which ones are "fatal" and which are
"non-fatal". Refer to the "Claim & Reference File Edit Validation" topic for a more
complete discussion of the claim edit validation process and the Edit Validation Errors
List form. If edit errors exist, you will have the option to correct the errors or save the
request with errors. Click the "Save With Errors" button to save a request that contains
only non-fatal errors. Such requests are assigned the "has errors" (ERR) status. Click
the "Save With Fatal" button to save a request that contains fatal errors. Such requests
are assigned the "has fatal errors" (ERF) status. Requests with an "ERF" status will not
be eligible for preparation.
If edit validation errors occur, several "Save" attempts may be required to correct and save a
"clean" service type eligibility benefit request. At any time, click the "Errors List" button to
review the remaining edit validation errors.
Common Service Type Eligibility Benefit Request Activities
The following hyperlinks provide additional instruction on several common service type
eligibility benefit request activities:
Refer to the "Adding a new eligibility benefit request" topic for more information on adding
eligibility benefit requests.
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Refer to the "Listing, modifying and maintaining eligibility benefit requests" topic for tips on
maintaining eligibility benefit requests from the Eligibility Benefit Request List form.
Refer to the "Preparing eligibility benefit request files for transmission" topic to learn about
preparing eligibility benefit requests into an ANSI-270 format file for transmission.
Refer to the "Viewing and maintaining eligibility benefit response files" topic to learn about
handling ANSI-271 response files returned from the Information Source (Payer).
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Roster Billing List Form Features
The PC-ACE Pro32 Roster Billing List form provides a versatile interface from which the user
can create, list, modify, print, and otherwise maintain Professional roster billings. Click the
"Professional Claims Processing" button on the PC-ACE Pro32 Main Toolbar to open the
corresponding Claims Menu form. Then select the "Maintain Roster Billings" item from the
Professional Claims Menu form's main "Roster" menu to open the Roster Billing List form. You
may reposition and resize this form if desired. The list can be easily sorted and filtered to
display only the roster billings of interest.
Sorting Roster Billings
The roster billing list may be sorted by Service Date, Provider, Roster Type, and Entry Date.
Simply select the desired sort order from the available "Sort By" radio buttons.
Filtering Roster Billings
The roster billing list may be filtered to display a select subset of roster billings by manipulating
the "Roster Billing List Filter Options" drop-down lists. Basic filter options include:
Location - filters the roster billing list to include only roster billings in the "to be
generated" (RL) or "generated" (GR) locations.
Status - filters the roster billing list to include only roster billings assigned a specific
status. The possible status codes are: "clean/ready" (CLN), "deleted" (DEL), "has fatal
errors" (ERF), and "has errors" (ERR).
Note: Note that selecting a status of "DEL" is the only way to view "deleted" roster
billings (which can be recovered until they are purged from the system).
When multiple filter criteria are specified, only those roster billings that meet all filter criteria will
be displayed.
Roster Billing Actions
The Roster Billing List form may also be used to perform specific actions on any individual
roster billing. To perform an action on a roster billing, simply select the roster billing from the
list and click the desired action button (along the lower edge of the form). The complete list of
roster billing actions can be accessed from the Roster Billing List form's main "Actions" menu
or from the convenient pop-up menu (accessed by right clicking the mouse over the selected
roster billing record). Available roster billing actions include:
Creating New Roster Billings -- Click the "New" button (or choose the "Create New
Roster" action) to create a new roster billing. See the "Adding a new roster billing" topic
for more details.
Viewing/Modifying Roster Billings -- Click the "View/Update" button (or choose the
"View/Update Selected Roster" action) to view and/or modify the selected roster billing.
See the "Professional Roster Billing Form" topic for details on using this roster billing
entry form.
Tip: The View/Update action is the default roster billing action. In addition to the
techniques described above, this action can also be invoked by double-clicking on
the desired roster billing record or by selecting the desired record and pressing the
"ENTER" key.
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Deleting Roster Billings -- Click the "Delete" button (or choose the "Delete Selected
Roster" action) to delete the selected roster billing. Deleted roster billings are assigned a
"DEL" status, and can be recovered (i.e., "un-deleted") if needed. See the "Purging
Roster Billings" action description below for instructions on permanently removing roster
billings from the PC-ACE Pro32 database.
Copying Roster Billings -- Click the "Copy" button (or choose the "Copy Selected
Roster" action) to copy the selected roster billing. The roster billing entry form will be
displayed containing the details of the newly copied roster billing. The "Service Date"
field is cleared automatically in the new roster billing. This roster billing copy function is
often used to duplicate a previous roster billing, greatly simplifying the process of billing
for periodic immunizations on a relatively consistent set of patients.
Generating Roster Billing Claims -- Click the "Generate" button (or choose the
"Generate Selected Roster" action) to automatically generate claims for the selected
roster billing. Upon completion of the claim generation process, you may view the roster
billing report if desired. A successfully generated roster billing is automatically moved to
the "generated" (GR) location. Refer to the "Listing, modifying and maintaining roster
billings" topic for more information on this claim generation process.
Note: PC-ACE Pro32 uses the claim import report preference settings to define the
default reporting options for the roster billing generation process. Refer to the
"Printing Preferences" topic for information on configuring claim import (and roster
billing generation) reports to be printed automatically or to a specific printer.
Viewing Roster Billing Reports -- Choose the "View Selected Roster Report" action
to preview the report for a previously generated roster billing. The report may be printed
from the preview screen if desired.
Purging Roster Billings -- Choose the "Purge Selected Roster" action to purge the
selected roster billing. Roster billings in the "to be generated" (RL) location must be
deleted before being purged.
Attention: Purged roster billings are permanently deleted from PC-ACE
Pro32 … they cannot be recovered.
Refreshing the Roster Billing List -- Choose the "Refresh Roster List" action to
refresh the current Roster Billing List form contents. This action can be useful in a multiuser installation to be sure that the roster billing list properly reflects additions and/or
modifications made by other users.
Note: You will notice that only applicable actions are enabled for use in the main
"Actions" menu or pop-up menu. For example, it makes no sense to "view the roster
report" of a roster billing that has yet to be generated, so this action will be disabled for
roster billings in the "RL" location.
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The Professional Roster Billing Form
The Professional Roster Billing Form provides access to all data elements of a Professional
roster billing. New roster billings are entered and existing roster billings are viewed and/or
modified from this form. The form consists of the following major tabs:
Patient Info & General - includes general roster, patient and insured information fields.
The upper section of this tab presents those fields that will be common to all claims
generated from the roster billing. The lower section of the form presents those fields that
are unique to each claim generated from the roster billing.
Extended Roster Info - includes any supplemental common fields that may be required
in certain situations.
Click the appropriate tab or simply press the "PAGE UP" and " PAGE DOWN" keys to move
between these major roster billing form sections.
Entering Roster Billing Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Use the "UP ARROW" and
"DOWN ARROW" keys to move up and down through the roster billing form fields,
respectively.
A number of productivity enhancing features are available during roster billing data entry:
Fixed-List Lookups - The roster billing form supports fixed-list lookups on many of its
fields. Fixed-list lookups apply to fields whose list of valid values can be determined in
advance. For example, "Patient Sex" typically has 3 possible values: "M" (male), "F"
(female), and "U" (unknown).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the roster billing form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The roster billing form supports variable-list lookups on a
number of its fields. Variable-list lookups apply primarily to fields whose values are
selected from reference files. Many of the variable-list lookups use other roster billing
field values to filter the presented list. For example, the provider lookup presents only
those provider records applicable to the roster billing being entered. In addition, variablelist lookups often retrieve data used to fill in other roster billing form fields. For example,
selection of a Patient from the variable-list lookup completes numerous patient-related
fields on the roster billing form. Access variable list lookups using the same method
described above for fixed-list lookups.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most roster billing form
fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
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derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
Descriptive Field Hints - Most roster billing form fields have field hints that provide a
brief description of the field's purpose. These hints are often called "fly-over" hints, since
they become visible when the mouse pointer moves over the specified field (without
actually selecting the field). This feature can be disabled in the general preferences
settings if desired.
Line Item Scrolling - The lower section of the "Patient Info & General" tab displays 5
patient billing lines at a time. For roster billings that contain more than 5 patients, the
user may scroll through the patient billing lines one line at a time or one page (i.e., 5
lines) at a time using the buttons provided along the right edge of this tab.
Tip: You can also use the up/down arrow keys to move from line to line, scrolling
when appropriate. Type "<ALT><PAGE UP>" (press the "Page Up" key while
holding the "ALT" key down) or "<ALT><PAGE DOWN>" to scroll up/down through
all roster billing lines one page at a time.
Billing Line Item Features - The following productivity features are available for roster
patient billing lines:
Current Billing Line Tracking - The Patient Info & General tab contains two
second-level tabs. The first second-level tab (Patient Information) displays the
patient information for the roster billing line items. The other second-level tab is
linked to the currently selected billing line on the Patient Information tab. As the
cursor moves from one billing line to another on the Patient Information tab, the
other second-level tab will track the new current billing line. This technique provides
an efficient method of providing access to additional data elements on a potentially
large number of roster billing lines. Notice that the Insured & Misc Info tab caption
always reports the current billing line for reference.
Billing Line Field Duplication - Pressing the "F4" key while positioned on a specific
roster billing line field will copy the value of that single field from the previous line
into the current line.
Tip: Pressing the "F4" key while positioned on the "Address Line 1" field will
copy all address fields from the previous line into the current line.
Line Deletion - Press the "F7" key (or the "<ALT>D" key sequence) while
positioned on any field on a roster billing line to delete the line. You will be prompted
to confirm the deletion.
Advance To Next Line - Press the "F8" key while positioned on any field on a roster
billing line to automatically advance the cursor to the first field of the next line, skipping
over any remaining fields on the current line.
Automatic Patient Control Number Generation (optional) – The roster billing form
supports automatic generation of the Patient Control Number field. The decision to
enable automatic PCN generation is typically made by the distributor. When this feature
is disabled, the PCN field must be entered manually or looked up from the Patient
reference file (via the "F2" shortcut key).
Tip: Lookups from the Patient reference file may be performed even when automatic
PCN generation is enabled. In this scenario, the lookup operation will retrieve all
patient information except the PCN.
When the focus leaves a roster billing form field (either by pressing the "TAB" key or clicking
on a new field), an edit validation process is performed on the field losing the focus. Edits
performed at this time are referred to as "field-level" edits. If a field-level edit validation error
occurs, you will receive an audible response and the edit validation error message will be
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displayed in the lower left corner of the roster billing form. In addition, the focus will remain on
the field so that you can correct the problem if desired. If you choose not to correct the data at
this time, simply press the "TAB" key again to move to the next field. Refer to the "Claim &
Reference File Edit Validation" topic for a more complete discussion of the roster billing edit
validation process.
Saving & Canceling Roster Billings
After completing data entry on the roster billing form, click the "Save" button (or type
"<ALT>S") to save and exit the roster billing. Alternatively, click the "Cancel" button to
abandon any changes and exit the roster billing. When an attempt is made to save a roster
billing, an edit validation process is performed on all fields on the form. This process includes
re-evaluating all "field-level" edits (as defined above). In addition, all "file-level" edits are
evaluated. File-level edits are evaluated only when the roster billing is saved, and are typically
those edits that require multiple data elements from the roster billing in order to be evaluated. If
no edit validation errors occur, the roster billing is saved with a "clean" (CLN) status. If,
however, one or more edit validation errors occur, you will be presented with the Edit
Validation Errors List form. This form lists all the edit validation errors that have occurred,
indicating which ones are "fatal" and which are "non-fatal". Refer to the "Claim & Reference
File Edit Validation" topic for a more complete discussion of the edit validation process and the
Edit Validation Errors List form. If edit errors exist, you will usually have the option to correct
the errors or save the roster billing with errors. If a fatal error exists on the "Payer ID",
"Provider ID/No.", "Service Date", or "Type" field, however, you must correct the error before
saving the roster billing. Click the "Save With Errors" button to save a roster billing that
contains only non-fatal errors. Such roster billings are assigned the "has errors" (ERR) status.
Click the "Save With Fatal" button to save a roster billing that contains fatal errors. Such roster
billings are assigned the "has fatal errors" (ERF) status. Claims cannot be generated from a
roster billing with an "ERF" status. If edit validation errors occur, several "Save" attempts may
be required to correct and save a "clean" roster billing. At any time, click the "Errors List"
button to review the remaining edit validation errors.
Miscellaneous Roster Billing Form Topics
The following comments cover any miscellaneous features of the Professional Roster Billing
Form:
Displaying Audit information - Click the picture button in the upper right corner of the
form to display audit information for this roster billing. This audit information includes the
date the roster billing was created, the last modification date, and the User ID of the user
that modified the roster billing last.
Common Roster Billing Activities
The following hyperlinks provide additional instruction on several common roster billing
activities:
Refer to the "Adding a new roster billing" topic for more information on adding roster
billings.
Refer to the "Listing, modifying and maintaining roster billings" topic for tips on maintaining
roster billings from the Roster Billing List form.
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Home Health Plan of Care List Form Features
The PC-ACE Pro32 Home Health Plan of Care List form provides a versatile interface from
which the user can create, list, modify, print, and otherwise maintain Plans of Care. Click the
"Institutional Claims Processing" button on the PC-ACE Pro32 Main Toolbar to open the
Institutional Claims Menu form. Then select the "Attachments" and "Maintain HH Plans of
Care" menu items on the Institutional Claims Menu form to open the Plan of Care List form.
You may reposition and resize this form if desired. The list can be easily sorted and filtered to
display only the plans of interest.
Sorting Plans of Care
The plan list may be sorted by Patient Control Number (PCN), Patient Name, Entry Date, and
Start of Care (SOC) Date. Simply select the desired sort order from the available "Sort By"
radio buttons.
Filtering Plans of Care
The Plan of Care List may be filtered to display a select subset of plans using the Advanced
Filter Options (accessible from the "Filter" main menu item). These advanced options permit
filtering on the plan's patient PCN, patient name, provider, as well as a selection of date fields.
When multiple filter criteria are specified, only those plans that meet all filter criteria will be
displayed. A convenient "Clear Filters" item is also available from the "Filter" main menu to
quickly remove any existing filter criteria.
Plan of Care Actions
The Plan of Care List form may also be used to perform specific actions on any individual plan
or a group of selected plans. To perform an action on an individual plan, simply select the plan
from the list and click the desired action button (along the lower edge of the form). The
complete list of plan actions can be accessed from the Plan of Care List form's main "Actions"
menu or from the convenient pop-up menu (accessed by right clicking the mouse over the
selected plan). Available plan actions include:
Creating New Plans of Care -- Click the "New" button (or choose the "Create New
Plan of Care" action) to create a new plan. See the "Adding a new Home Health Plan of
Care" topic for more details.
Viewing/Modifying Plans of Care -- Click the "View/Update" button (or choose the
"View/Update Selected Plan of Care" action) to view and/or modify the selected plan.
See the "Home Health Plan of Care Form" topic for details on using the PC-ACE Pro32
Plan of Care entry form.
Tip: The View/Update action is the default plan action. In addition to the techniques
described above, this action can also be invoked by double-clicking on the desired
plan record or by selecting the desired record and pressing the "ENTER" key.
Tip: Holding down the "SHIFT" key while invoking the View/Update action on an
eligible plan will force an automatic save attempt on the plan. This is a shortcut
technique equivalent to invoking the View/Update action and subsequently clicking
the "Save" button on the plan entry form. Eligible plans are those with a status of
"unprocessed" (UNP), "has errors" (ERR), or "has fatal errors" (ERF).
Copying Plans of Care -- Click the "Copy" button (or choose the "Copy Selected Plan
of Care" action) to copy the selected plan. If the plan being copied includes a Medical
Update (CMS-486) section, you will be given the option to include or omit this data on
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the new plan. The Plan of Care entry form will be displayed containing the details of the
newly copied plan. Make modifications as required and save the new plan.
Deleting Plans of Care – Click the "Delete" button (or choose the "Delete Selected
Plan of Care" action) to delete the selected plan.
Attention: Deleted plans are permanently purged from PC-ACE Pro32 … they
cannot be recovered.
Printing Plans of Care -- Choose the "Print Selected Plan of Care" action to print the
selected plan. See the "Printing Home Health Plans of Care" topic for more details.
Refreshing the Plan of Care List -- Choose the "Refresh Plan of Care List" action (or
press the "F5" function key) to refresh the current Plan of Care List form contents. This
action can be useful in a multi-user installation to be sure that the list properly reflects
plan additions and/or modifications made by other users.
Note: You will notice that only applicable actions are enabled for use in the main
"Actions" menu or pop-up menu. For example, the "all checked" actions will be
enabled only when one or more plans in the list are checked.
Actions on Multiple Plans of Care
Some actions can be performed on multiple plans at once. Multiple plan selection is
accomplished by "checking" the plans of interest and subsequently performing one of the "…
All Checked Plans of Care" actions. To check a plan, click the left mouse button over the
checkbox in the first column of the desired list row. Alternatively, all plans in the current list can
be checked using the "Check All Plans of Care" item from the list's pop-up menu. Use the
form's flexible advanced filter techniques to display only the subset of plans to be printed,
deleted, etc. Then simply check all plans and perform the desired action on all checked plans
at once.
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The Home Health Plan of Care Form
The Home Health Plan of Care Form provides access to all data elements of a Home Health
Plan of Care. New plans are entered and existing plans are viewed and/or modified from this
form. The Home Health Plan of Care Form has been designed to provide a data entry flow
resembling that of the printed Home Health Certification And Plan of Care (CMS-485) and
Medical Update And Patient Information (CMS-486) forms. Plan fields are grouped logically on
five major tabs:
Plan of Care (485-1) – includes most of the CMS-485 form's general plan and patient
information fields, as well as all diagnosis and procedure codes/dates. Patient
medication information, the DME and supplies listing, and the safety measures
narratives are also included on this tab.
Plan of Care (485-2) - includes all remaining CMS-485 form fields (e.g., patient status
selections, diagnosis and treatment orders, goals/rehab narrative, and physician
information).
Medical Update (486-1) - includes all non-narrative fields from the CMS-486 form. This
tab also provides line item entry of all service/treatment information per discipline
(including actual/projected visits, frequency/duration, and applicable treatment codes).
Medical Update (486-2) - includes all remaining CMS-486 narrative fields.
Miscellaneous - includes any miscellaneous fields which are not specifically assigned to
an CMS-485/486 form location, but which may be required in certain situations. This tab
also provides line entry of any expanded narrative information to be associated with a
specified form location.
Tip: The two "Medical Update" tabs will be visible only if the "Include Medical Update
(Form 486)" checkbox on the "Plan of Care (485-1)" tab is checked. This feature allows
the user to optionally include the Medical Update (CMS-486) data with the Plan of Care.
Click the appropriate tab or simply press the "PAGE UP" and "PAGE DOWN" keys to move
between these major Plan of Care form sections.
Entering Plan of Care Data
Click on any field to activate it for data entry, or press the "TAB" key to move from field to field
in a predefined sequence (generally left-to-right and top-to-bottom). Use the "UP ARROW" and
"DOWN ARROW" keys to move up and down through the plan form fields, respectively.
A number of productivity enhancing features are available during plan data entry:
Fixed-List Lookups - The Plan of Care form supports fixed-list lookups on many of the
plan's fields. Fixed-list lookups apply to fields whose list of valid values can be
determined in advance. For example, the patient's sex field typically has 3 possible
values: "M" (male), "F" (female), and "U" (unknown).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the Plan of Care form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - The Plan of Care form supports variable-list lookups on a
number of the plan's fields. Variable-list lookups apply primarily to fields whose values
are selected from reference files. Some variable-list lookups use other plan field values
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to filter the presented list. For example, treatment code lookups present only those
codes applicable to the specified discipline. In addition, variable-list lookups often
retrieve data used to fill in other Plan of Care form fields. For example, selection of a
Patient PCN from the variable-list lookup completes numerous patient-related fields on
the plan. Access variable list lookups using the same method described above for fixedlist lookups.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the general preferences settings if desired.
Intelligent Groups Tabs – The Plan of Care form contains a number of field "groups".
Examples of such groups include Other Diagnosis, Functional Limitations, and Mental
Status codes. Fields in these groups are always completed sequentially. Therefore,
when a field in one of these groups is left empty, it can be assumed that data entry in the
group is complete. When the "TAB" key is pressed, the remaining fields in that group will
be skipped and the cursor will be positioned on the first field in the tab sequence beyond
the group fields.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most Plan of Care form
fields.
Date Completion - Date values may be entered with or without the century for
convenience. PC-ACE Pro32 uses a user-definable century pivot year to automatically
derive the century when omitted. To insure accuracy, birthdate fields require that a full 4digit year be entered.
Descriptive Field Hints - Most Plan of Care form fields have field hints that provide a
brief description of the field's purpose. These hints are often called "fly-over" hints, since
they become visible when the mouse pointer moves over the specified field (without
actually selecting the field). This feature can be disabled in the general preferences
settings if desired.
Line Item Scrolling – A variable number of Service/Treatment lines (on the "Medical
Update (486-1)" tab) and Expanded Narrative lines (on the "Miscellaneous" tab) may be
entered on a Plan of Care form. This form displays two Service/Treatment lines and
three Expanded Narrative lines at a time. For plans that contain additional line items, the
user may scroll through the line items one line at a time or one page at a time using the
buttons provided along the right edge of the respective tabs.
Tip: You can also use the up/down arrow keys to move from line to line, scrolling
when appropriate. Type "<ALT><PAGE UP>" (press the "Page Up" key while
holding the "ALT" key down) or "<ALT><PAGE DOWN>" to scroll up/down through
all line items one page at a time.
Line Item Deletion - Press the "F7" key while positioned on any field of a
Service/Treatment line or Expanded Narrative line to delete the line. You will be
prompted to confirm the deletion.
When the focus leaves a Plan of Care form field (either by pressing the "TAB" key or clicking
on a new field), an edit validation process is performed on the field losing the focus. Edits
performed at this time are referred to as "field-level" edits. If a field-level edit validation error
occurs, you will receive an audible response and the edit validation error message will be
displayed in the lower left corner of the plan form. In addition, the focus will remain on the field
so that you can correct the problem if desired. If you choose not to correct the data at this time,
simply press the "TAB" key again to move to the next field. Refer to the "Claim & Reference
File Edit Validation" topic for a more complete discussion of the plan edit validation process.
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Saving & Canceling Plans of Care
After completing data entry on the Plan of Care form, click the "Save" button (or type
"<ALT>S") to save and exit the plan. Alternatively, click the "Cancel" button to abandon any
changes and exit the plan.
When an attempt is made to save a plan, an edit validation process is performed on all fields
on the plan. This process includes re-evaluating all "field-level" edits (as defined above). In
addition, all plan "file-level" edits are evaluated. File-level edits are evaluated only when the
plan is saved, and are typically those edits that require multiple data elements from the plan in
order to be evaluated. If no edit validation errors occur, the plan is saved with a "clean" (CLN)
status. If, however, one or more edit validation errors occur, you will be presented with the Edit
Validation Errors List form. This form lists all the edit validation errors that have occurred,
indicating which ones are "fatal" and which are "non-fatal". Refer to the "Claim & Reference
File Edit Validation" topic for a more complete discussion of the plan edit validation process
and the Edit Validation Errors List form. If edit errors exist, you will usually have the option to
correct the errors or save the plan with errors. If a fatal error exists on the "PCN" field,
however, you must correct the error before saving the plan. Click the "Save With Errors"
button to save a plan that contains only non-fatal errors. Such plans are assigned the "has
errors" (ERR) status. Click the "Save With Fatal" button to save a plan that contains fatal
errors. Such plans are assigned the "has fatal errors" (ERF) status.
If edit validation errors occur, several "Save" attempts may be required to correct and save a
"clean" plan. At any time, click the "Errors List" button to review the remaining edit validation
errors.
Miscellaneous Plan of Care Form Topics
The following comments cover a few miscellaneous features of the Home Health Plan of Care
Form:
Entering Free-Form Narrative Data - The free-form narrative fields on the Plan of Care
form will automatically wrap to the next line as typing proceeds beyond the right margin
of the control. It is not necessary to enter any manual carriage returns in a narrative field.
If, however, a "hard" carriage return is desired, simply press the ENTER key and resume
typing on the next line of the narrative control.
Displaying Audit information - Click the picture button in the upper right corner of the
"Plan of Care (485-1)" tab to display audit information for this plan. This audit information
includes the date the plan record was created, the last modification date, and the User
ID of the user that modified the plan last.
Common Plan of Care Activities
The following hyperlinks provide additional instruction on several common plan activities:
Refer to the "Adding a new Home Health Plan of Care" topic for more information on
adding plans.
Refer to the "Listing, modifying and maintaining Plans of Care" topic for tips on
maintaining plans from the Home Health Plan of Care List form.
Refer to the "Printing Home Health Plans of Care" topic to learn about printing plans.
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Reference File Maintenance Form
The Reference File Maintenance form provides an interface to access all PC-ACE Pro32
reference files. Click the "Reference File Maintenance" button on the PC-ACE Pro32 Main
Toolbar to open the Reference File Maintenance form. The form consists of up to 5 major tabs
("Patient", "Payer", "Provider (Inst)", "Provider (Prof)", and "Codes/Misc."). If you are licensed
for only Institutional claims processing or only Professional claims processing, then you will
see only 4 tabs and the provider tab will be labeled simply "Provider". You may reposition and
resize this form if desired. The following is a brief explanation of these major tabs, including the
operations available on each.
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Patient - provides access to maintain general patient information as well as primary,
secondary, and tertiary insured details. Setup of the Patient reference file is optional.
Patient information from this reference file is available for lookup during claim entry. The
Patient tab provides a convenient "Sort By" selection that quickly sorts the Patient list by
"Patient PCN" or "Patient Name". Operations available include:
To add a new patient record, click the "New" button and enter the new patient record
information. Refer to the "Adding and maintaining patients" topic for more
information.
To view or modify an existing patient record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To delete an existing patient record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Payer - provides access to maintain system payer information and PrintLink matching
descriptions. Setup of the Payer reference file is mandatory (although it may be setup in
advance by your distributor). All payers referenced on claims must exist in the Payer
reference file, with the exception of the special "dump" payer (Payer ID=99999). The
Payer tab provides a convenient "Sort By" selection that quickly sorts the Payer list by
"Payer ID", "Payer Description", "Payer LOB" or "Payer State". Operations available
include:
To add a new payer record, click the "New" button and enter the new payer record
information. Refer to the "Adding and maintaining payers" topic for additional
information on payer and PrintLink matching description requirements.
To view or modify an existing payer record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To create a new payer record that is similar to an existing record, select the desired
payer record, click the "Copy" button and change only the desired fields. This
feature makes it easy to create multiple payer records for the same payer to support
more than one line of business (LOB).
To delete an existing payer record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Click the "PrintLink Matching Descriptions" button while viewing a Payer's details
to view/edit the PrintLink matching strings for the selected payer. Refer to the
"Adding and maintaining payers" topic for more details.
Provider (Inst) - provides access to maintain the providers to be referenced on
Institutional claims. Setup of the Institutional Provider reference file is required to process
Institutional claims. All providers referenced on Institutional claims must be represented in
this reference file. The Institutional Provider tab provides a convenient "Sort By" selection
that quickly sorts the Provider list by LOB", "Provider Name", "Provider ID", and "Tag".
Operations available include:
Main Toolbar & Forms
To add a new Institutional provider record, click the "New" button and enter the new
provider information. If providers already exist in this reference file, you will have the
option to create a completely new provider record, or inherit and associate the new
provider record with the provider record currently selected in the list. Select the
desired creation options and click the "OK" button to continue. Refer to the "Adding
and maintaining providers (Institutional)" topic for a discussion of these creation
options and their applicability.
To view or modify an existing provider record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To delete an existing provider record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Attention: Claims are linked to provider records by an internal control number.
Deleting a provider record will irrevocably break any such links that may exist to
claims in the system. The Provider Deletion Confirmation form outlines
alternatives to deletion, and provides a convenient utility to determine how
many claims reference the provider record to be deleted.
Provider (Prof) - provides access to maintain the providers to be referenced on
Professional claims. Setup of the Professional Provider reference file is required to
process Professional claims. All providers referenced on Professional claims must be
represented in this reference file. The Professional Provider form provides a convenient
"Sort By" selection that quickly sorts the Provider list by LOB", "Type", "Provider/Group
Name", "Provider ID", "Group Label.", and "Tag". Operations available include:
To add a new Professional provider record, click the "New" button and enter the new
provider information. If providers already exist in this reference file, you will have the
option to create a completely new provider record, or inherit and associate the new
provider record with the provider record currently selected in the list. Select the
desired creation options and click the "OK" button to continue. Refer to the "Adding
and maintaining providers (Professional)" topic for a discussion of these creation
options and their applicability.
To view or modify an existing provider record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To delete an existing provider record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Attention: Claims are linked to provider records by an internal control number.
Deleting a provider record will irrevocably break any such links that may exist to
claims in the system. The Provider Deletion Confirmation form outlines
alternatives to deletion, and provides a convenient utility to determine how
many claims reference the provider record to be deleted.
Codes/Misc - provides access to the core PC-ACE Pro32 codes and miscellaneous
reference files. Refer to the "Codes & Miscellaneous Reference Files Overview" topic for
additional information on each of these reference files.
Common Reference File Form Features
A number of productivity enhancing features are available while entering reference file
information.
Fixed-List Lookups - Fixed-list lookups are available on many of the fields on these
forms. Fixed-list lookups apply to fields whose list of valid values can be determined in
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advance. For example, "Patient Sex" typically has 3 possible values: "M" (male), "F"
(female), and "U" (unknown).
USAGE: Access the lookup list for a field by positioning the cursor on the field and
pressing the "F2" function key (or right-clicking the mouse). When an item from the list is
selected, its value is automatically entered in the form field.
Tip: Type "<ALT>F2" (press the "F2" key while holding the "ALT" key down) to
identify all fields that support a lookup list. Press the "ESC" key to disable the
flashing notification.
Variable-List Lookups - Variable-list lookups are available on many of the fields on
these forms. Variable-list lookups apply primarily to fields whose values are selected
from other reference files. Such lookups often retrieve data used to fill in other form
fields. For example, if you use the variable-list lookup feature to select a Payer ID on the
"Primary Insured" tab of the Patient Information form, the Payer Description and Payer
LOB will be retrieved as well. Access variable list lookups using the same method
described above for fixed-list lookups.
Automatic Field Tabs - When entering data in a field, an automatic tab will occur when
the field has been completely filled. For example, entering a single character in a onecharacter field will automatically position the cursor on the next field in the tab sequence.
This feature can be disabled in the "General Preferences" settings if desired.
Cancel Field Changes - If a change is inadvertently made to the contents of a field,
press the "ESC" key to cancel this change and restore the field's value to what it was
when the field received the focus. This feature is available for most fields on any of the
reference file information forms.
Edit Validation - Edit validation rules apply to patient, payer, provider, and submitter
reference file records. When a new or modified patient, payer, provider, or submitter
record is saved, an edit validation process is performed on all fields. If no edit validation
errors occur, the updated record is saved. If, however, one or more edit validation errors
occur, you will be presented with the Edit Validation Errors List form. This form lists all
the edit validation errors that have occurred, indicating which ones are "fatal" and which
are "non-fatal". Refer to the "Claim & Reference File Edit Validation" topic for a more
complete discussion of the Edit Validation Errors List form. If any fatal edit errors exist,
you must correct them before the record can be saved. If only non-fatal edit errors exist,
you will have the option to correct the errors or save the record with errors. Click the
"Save With Errors" button to save a record that contains only non-fatal errors.
Descriptive Field Hints - Most reference file fields have field hints that provide a brief
description of the field's purpose. These hints are often called "fly-over hints", since they
become visible when the mouse pointer moves over the specified field (without actually
selecting the field). This feature can be disabled in the general preference settings if
desired.
Common Reference File Filter Options
Many of the reference file forms provide a common set of "List Filter Options" that can be
helpful in locating a specific record in the list. These common filter options are defined as
follows:
"Show all …(no filter applied)" - When selected, any existing filter is removed and all
records in the list are displayed.
"Filter list to include … starting with …" - When selected, the list is filtered to include
only those records whose PCN, ID, code, name, or description starts with the pattern
entered in the adjacent filter control. The filter is dynamically re-applied as characters are
added to (or deleted from) the pattern.
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Tip: This filter option is invoked automatically if the user types one or more
alphanumeric characters while the focus is on the list (which it is by default when
the form is opened). This behavior permits the user to easily filter the list if the first
few characters of the code or description are known. The user may then use the
standard list navigation keys to move around in the filtered list. Once the desired
record is selected, the user may press the "ENTER" key to "view/update" (or
"select" in a lookup context) the highlighted record. These features are designed to
increase operator efficiency by minimizing the need to use the mouse.
"Filter list to include descriptions containing …" - When selected, the list is filtered to
include only those records whose description field value contains the pattern entered in
the adjacent filter control. Click the "Apply" button (or press the "ENTER" key) after
entering the search string to perform the filter operation.
"Show only providers associated with selected provider" - When selected, filters the
list to include only those provider records associated with the currently selected provider
record. This filter option is only available with the Institutional and Professional provider
lists. Refer to the "Adding and maintaining providers (Institutional)" and "Adding and
maintaining providers (Professional)" topics for a discussion of provider associations.
Common Reference File Sort & Selection Features
Most reference file forms support a common set of sort and selection features that can be
helpful in locating a specific record in the list. These features are designed to increase operator
efficiency by minimizing the need to use the mouse (especially when accessing lookup lists
during manual claim entry). These common features include:
Quick Sort Order Toggle – In addition to the standard "Sort By" selection controls, most
reference file forms also recornize the "F3" function key as a way to quickly toggle
between the most commonly desired sorting selections. Typically, the "F3" key can be
used to toggle between the "ID" (or "Code") sort order and the "Name" (or "Description")
sort order.
List Navigation Keys – Most reference file forms recognize all common list navigation
keys. These include the up/down arrow keys (moves up/down one record), page
up/down keys (moves up/down one page), and home/end keys (moves to the first/last
record). In addition, the "<TAB>" key can be used to move down through the currently
visible records, and the "<SHIFT><TAB>" key combination can be used to move up
through the visible records. Note: These navigation keys are recognized only when the
list is the active control (i.e., has the focus).
Reference File Reports
Common reference file reports are accessible from the Reference File Maintenance form's
main "Reports" menu. Currently available reports include:
Patient List - previews and/or prints a summary report of all (or a selection of) patient
records. The Patient List Report Filter Criteria form will be displayed to allow the user to
restrict the patient records to be included in the report. Enter any desired report filter
criteria and preview or print the report as desired.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Adding and maintaining patients", "Adding and maintaining payers", "Adding
and maintaining providers (Institutional)", "Adding and maintaining providers
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(Professional)", and "Codes & Miscellaneous Reference Files Overview" topics for
additional information on these core PC-ACE Pro32's reference files.
Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Claim & Reference File Edit Validation
The term "edit" is commonly used in claims processing to describe a specific rule imposed on
a claim field (or combination of claim fields). The plural term "edits" refers to the collection of
individual rules imposed on a specific claim field or on the entire claim. Sequentially applying
all applicable edits on a claim field (or all claim fields) is referred to as the "edit validation"
process. The set of rules (edits) to be imposed on a claim's fields varies with the type of claim,
and is typically defined by the distributor. PC-ACE Pro32 provides a powerful and flexible
system for defining, maintaining, and validating claim edits. In addition, edits are available for
validating Institutional Home Health Plans of Care, Professional roster billings, as well as
records in the Patient, Payer, Provider, and Submitter reference files. This discussion will focus
on the claim editing process, however, the same concepts and procedures apply to plan of
care, roster billing, patient, payer, provider, and submitter editing unless specified otherwise.
Field-Level vs. File-Level Edits - Edits in PC-ACE Pro32 are defined at the time they are
created as one of two possible types:
Field-Level - During claim entry, when the focus leaves a claim form field (either by
pressing the "TAB" key or clicking on a new field), an edit validation process is
performed on the field losing the focus. Edits performed at this time are referred to as
"field-level" edits. If a field-level edit validation error is detected, you can either correct
the problem at that time or leave it for later.
File-Level - Edits that are validated only when an attempt is made to save the claim are
referred to as "file-level" edits. File-level edits are typically those that require multiple
data elements from the claim in order to be evaluated. For example, looking for duplicate
procedure codes on all lines of a claim is a task that can only be performed correctly
when all lines have been entered. As such, this type of duplicate check is the ideal
candidate for a "file-level" edit.
Note: All field-level edits for the entire claim are re-evaluated when an attempt is made to
save the claim. This is necessary to catch those field-level edit errors that were never
corrected, and to catch any new edit errors that may have been introduced by other
changes on the claim.
Fatal vs. Non-Fatal Edits - Edits in PC-ACE Pro32 are defined at the time they are created as
either "fatal" or "non-fatal":
Fatal Edits - Fatal edits describe rules that should never be broken. For example, a
claim has no useful meaning until at least one valid payer has been specified. Therefore,
a "fatal" edit exists to ensure that a valid payer has been specified. Claims with fatal
errors can be saved, unless the fatal errors exist on one of the claim's key fields. Key
fields include "LOB", "PCN" and "TOB" for Institutional claims and "LOB" and "PCN" for
Professional claims. Claims saved with fatal errors will not be eligible for preparation into
an electronic (EMC) file. All fatal errors in reference file records must be corrected before
the user can save the record. There are relatively few fatal edits defined in PC-ACE
Pro32.
Non-Fatal Edits - Non-fatal edits describe rules that should probably not be broken,
however, PC-ACE Pro32 will look the other way if they are. Claims containing only nonfatal edit errors can be saved (and even prepared into an EMC file if desired). It is up to
the user to decide when a non-fatal edit validation error can be ignored.
Handling Edit Validation Errors
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Field-level edit validation errors are reported as the focus leaves the offending field during
claim entry. If such an error occurs, you will receive an audible response and the edit validation
error message will be displayed in the lower left corner of the claim form. In addition, the focus
will remain on the field so that you can correct the problem if desired. If you choose not to
correct the data at this time, you can simply press the "TAB" key again to move to the next
field.
When an attempt is made to save the claim, an edit validation process is performed on all
claim fields. This process includes re-evaluating all "field-level" edits. In addition, all claim "filelevel" edits are evaluated. If no edit validation errors occur, the claim is saved with a "clean"
(CLN) status. If, however, one or more edit validation errors occur, you will be presented with
the Edit Validation Errors List form (unless disabled in the General Preference settings). This
form lists all the edit validation errors that have occurred, flagging fatal errors with a red "X"
graphic. Double-click on any of the listed errors to jump directly to the offending field on the
claim form. Claims with fatal errors can be saved, unless the fatal errors exist on one of the
claim's key fields. Key fields include "LOB", "PCN" and "TOB" for Institutional claims and
"LOB" and "PCN" for Professional claims. Click the "Save With Errors" button to save a claim
that contains only non-fatal errors. Such claims are assigned the "has errors" (ERR) status.
Click the "Save With Fatal" button to save a claim that contains fatal errors. Such claims are
assigned the "has fatal errors" (ERF) status. Claims with an "ERF" status will not be eligible for
preparation into an electronic (EMC) file. Fatal edit errors on reference file records must be
corrected before the user can save the record.
If edit validation errors are reported, several "Save" attempts may be required to correct and
save a "clean" claim. At any time, click the "Errors List" button to review the remaining claim
edit validation errors. Remember that file-level edit errors are only re-checked when the claim
is saved. Therefore, these edit errors will remain in the list even though the problem may have
already been corrected. The next claim save attempt will clear any corrected file-level edit
validation errors from the list.
Tip: When the Edit Validation Errors List form closes, all claim fields reporting edit
validation errors will begin flashing. By default, the normal tab sequence is overridden
and will now jump between these error fields. This special tab feature is intended to
speed up the process of correcting multiple edit validation errors, and can be disabled in
the "general preferences" settings if desired. Press the "ESC" key to stop the error fields
from flashing and to restore the normal tab sequence.
Note: The "Errors List" button is not available on the Patient, Payer, Provider, and
Submitter reference file information forms.
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Security & User Maintenance
The Security & User Maintenance features accessible from the main "Security" menu allow a
System Administrator to add and delete system users, and to maintain security access
permissions for these users. Select the "Add/Update User" item from the main "Security"
menu to display the current system user list.
To add a user, click the "New" button. Each user must be assigned a User ID, Password
and Name. During the user creation process, it is important to set the user's access
permissions to allow complete or selective access to activities within the system. The
user permissions are grouped as follows:
Institutional Claim Activities - specifies user permission to view, enter, modify,
delete, import, process, prepare, and archive Institutional claims.
Professional Claim Activities - specifies user permission to view, enter, modify,
delete, import, process, prepare, and archive Professional claims.
Reference File Activities - specifies user permission to view and update
reference files.
Miscellaneous Activities - specifies user permission to access data
communications and system utilities, schedule claim activities, perform database
maintenance and system restores.
Security Maintenance Activities - specifies user permission to add and modify
system users and their permission settings.
Tip: Check the checkbox next to the permission to allow access to the activity.
Click the "Check All" and "Clear All" buttons to quickly check or un-check all user
permission checkboxes.
Attention: Grant "Security Maintenance Activities" permissions only to users
who need access to add/delete users and set user permissions.
To modify the password, name, or permissions for an existing user, select the user from
the Security List and click the "View/Update" button (or double-click the selection).
To delete a user, select the user from the Security List, click the "Delete" button and
confirm the deletion.
Attention: If changes are made to a user profile, the change will not go into effect until
the next time that user logs into system. The "Logout Current User" option, available
from the main "Security" menu, provides a convenient way to log out the current user
without exiting the system.
Note: As shipped, PC-ACE Pro32 is configured with a single default user with full
system access rights. The default user's User ID is "SYSADMIN" and password is
"SYSADMIN" as well. If you are logging into PC-ACE Pro32 for the first time, use this
default login (unless instructed otherwise by your distributor). If the default login does
not work, review the installation guidelines provided by your distributor. Distributors
often pre-configure the security system according to their own internal specifications. If
you still have difficulties logging into the system, contact your distributor for assistance.
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IMPORTANT: You should change the default user's password as soon as possible if
you are concerned about controlling user access at your facility.
Audit Tracking
An integrated audit tracking feature tracks modifications to user, claim, and reference files
records. You will see these audit buttons throughout PC-ACE Pro32. Click the button to display
the date the record was added, the date the record was last changed and the User ID
responsible for the last change.
System Security Level
The "Set Security Options" on the main "Security" menu provides access to PC-ACE
Pro32's security level setting. Three security levels are available:
Full password protection - requires users to enter a valid User ID and Password to log
in. User activity permissions are enforced at this security level.
Password required (no function checking) - requires users to enter a valid User ID and
Password to log in. User activity permissions are not enforced at this security level. Once
a user logs in, all system functions are allowed.
Password not required (User ID for Audit only) - requires users to enter only a valid
User ID to log in. This minimum-security level uses the User ID for audit purposes only.
Note: Access to the Security Options form requires a master System Administrator
password.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Adding or modifying a system user" topic for more information on user
maintenance.
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System Preferences
Preferences Overview
Many of the features in PC-ACE Pro32 are customizable. These preference settings are
organized on a tabbed dialog accessible from the PC-ACE Pro32 Main Toolbar's main "File"
menu. The major tabs on this dialog include:
General Preferences - includes settings to control general claim entry and other basic
aspects of the program's behavior.
Claim List Preferences - permits customization of the Institutional and Professional Claim
List forms, including column field selection, order, width and headings.
Claim Import Preferences - permits selection of the Institutional and Professional claim
import processing method as well as specification of an optional import preprocessor.
Printing Preferences - includes Institutional and Professional report and claim printing
options.
Data Communication Preferences - allows assignment of launch file paths and button
captions for external data communication programs.
Miscellaneous Preferences - includes settings to configure and control several
maintenance options and other miscellaneous features.
Click on the links above for a description of the available preference options in each category.
Note: Preference settings are workstation-specific. In a multi-user installation, each
client workstation may set these preferences to best suit their work flow and data entry
style.
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General Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The General Preferences tab settings control a
number of claim entry options as well as other basic aspects of PC-ACE Pro32 operation. A
description of each available option is included below:
Automatically tab at maximum field length during data entry - This option applies to
data entry in the Institutional Claim Form, Professional Claim Form, and a number of other
editable forms.
When checked, an automatic tab will occur when the field has been completely
filled. For example, entering a single character in a one-character field will
automatically position the cursor on the next field in the tab sequence.
When unchecked, the user must physically tab to the next field regardless of the
contents of the current field.
Tab key jumps between controls with edit errors when displayed - This option applies
to data entry in the Institutional Claim Form, Professional Claim Form, and a number of
other editable forms. When edit validation errors are encountered during a save operation,
the fields with errors will display in color (and optionally flash) to help the user locate them.
This option will be in effect while these fields are displayed in this manner.
When checked, the tab sequence will be altered to include only those fields with
errors (i.e., those fields that are displayed in color), allowing the user to rapidly
locate and correct the edit validation errors.
When unchecked, the normal tab sequence remains in effect at all times.
Tip: If this feature is enabled, press the "ESC" key to deactivate the special
notification error mode and return to normal tab operation.
Enable flashing notification method for controls with edit errors - This option applies
to the Institutional Claim Form, Professional Claim Form, and a number of other editable
forms. When edit validation errors are encountered during a save operation, the fields with
errors will display in color (and optionally flash) to help the user locate them. This option
controls whether or not the background of these fields will alternate (flash) between the
error color and the standard field color.
When checked, the background of the fields with edit validation errors will alternate
(flash) between their standard color and the appropriate error color.
When unchecked, the background of the fields with edit validation errors will be
statically displayed in the appropriate error color.
Warn on close when deferred claims tasks are scheduled - Scheduled claim import,
processing, and transmission activities can only be initiated when PC-ACE Pro32 is
running.
When checked, the user will be warned when exiting PC-ACE Pro32 if claims
activities are currently scheduled. The user will have the option to leave the program
running if desired.
When unchecked, no warnings will be issued when exiting PC-ACE Pro32.
Scheduled claims activities will not be performed while the program is down.
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Show descriptive field hints on claim and reference file forms - The Institutional Claim
Form, Professional Claim Form, and a number of other editable forms support "hint" (or
"fly-over") popup windows for each field. This "hint" provides a brief description of the data
required in the associated field.
System Preferences
When checked, the hint popup window will be displayed for a few seconds
whenever the mouse pointer moves over a supported field.
When unchecked, the field hints feature is disabled.
Present claims with errors for immediate editing during process runs - During
automated claim processing runs, the user may choose to review and/or correct claims
with edit validation errors as they are encountered. This option controls the default setting
for this "interactive" claim-processing mode.
When checked, claims with edit validation errors will be presented for review and/or
correction as soon as they are encountered in the automated claim processing run.
When unchecked, all claims in the automated processing run will be processed
without user intervention. Claims with edit validation errors can be worked from the
Claim List form after the automated processing run completes.
Note: The user may override this default setting when initiating an automated claim
processing run.
Use Charge Master reference file for Professional procedure code lookups - Controls
the data source for procedure code lookups in the Professional Claim Form.
When checked, the optional Charges Master reference file will serve as the source
for claim line procedure code lookups.
When unchecked, the master HCPCS Codes reference file will serve as the source
for claim line procedure code lookups.
Interpret Enter key as save request on claim entry and other editable forms Controls the action taken when the "ENTER" key is pressed on the claim entry and other
editable forms (e.g., Patient, Payer, Provider, and Submitter Information forms).
When checked, pressing the "ENTER" key during data entry on an applicable form
will invoke a save request. Thus, pressing the "ENTER" key is equivalent to clicking
the "Save" button.
When unchecked, pressing the "ENTER" key during data entry on an applicable
form will simply tab to the next field in the form's tab sequence.
Automatically display Edit Validation Error List when saving a claim that contains
errors – Determines whether the Edit Validation Errors List form is displayed automatically
when a claim containing edit validation errors is saved. This setting controls the display of
this errors list when a claim is saved manually (e.g., clicking the "Save" button on the
"Institutional Claim Form" or "Professional Claim Form") or when an implied save
operation is performed during an interactive claim processing run.
When checked, the Edit Validation Errors List will be displayed automatically during
a claim save operation if the claim contains edit validation errors. The user may
jump directly to the offending field for any listed edit validation error.
When unchecked, the Edit Validation Errors List will not be displayed automatically.
If the claim contains one or more edit validation errors, focus will be directed to the
field representing the first listed error. The user may view the Edit Validation Errors
List form if desired by clicking the "Error List" button on the claim entry form.
Automatically prompt for selection of non-unique Payer, Provider, and Physician IDs
– Determines whether or not a variable-list lookup operation will be initiated automatically
when the user enters a non-unique Payer ID, Provider ID, or Physician ID / UPIN while
hand-keying data into claims and selected reference files.
When checked, the appropriate variable-list lookup will be automatically initiated
whenever the hand-keyed ID / UPIN cannot be uniquely resolved in the
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corresponding reference file. The lookup list will automatically position itself on the
first of several records with the specified ID / UPIN. The user may then select the
desired record from the list.
When unchecked, the variable-list lookup will not be initiated and the non-unique ID
/ UPIN value will be left unresolved. In most cases, this will result in a subsequent
edit validation error. To correct this, the user should manually initiate a variable-list
lookup operation and select the desired unique record. Right-click the mouse (or
press the "F2" key) while positioned on the offending ID / UPIN field to manually
initiate the lookup operation.
Automatically focus on Patient PCN field for new Institutional hand-keyed claims –
Determines whether or not the cursor (focus) should be forced directly to the Patient PCN
field when the user manually creates a new Institutional claim. Enable this "patientcentered" configuration option for installations that make extensive use of the Patient
reference file. Upon patient selection, the claim's LOB field and primary provider field
(optional) will be populated automatically from information on-file in the patient record.
When checked, the cursor (focus) will be forced to the Patient PCN field when a
new Institutional claim is created. Upon patient selection, the claim's LOB will be
assigned automatically from the primary payer's LOB specified on the patient
record. The provider associated with the claim's primary payer will also be
populated automatically, if it has been specified on the patient record.
When unchecked, the cursor (focus) will be positioned normally on the LOB field.
The user is expected to enter or select the desired LOB for the new claim.
Automatically focus on Patient PCN field for new Professional hand-keyed claims –
Determines whether or not the cursor (focus) should be forced directly to the Patient PCN
field when the user manually creates a new Professional claim. Enable this "patientcentered" configuration option for installations that make extensive use of the Patient
reference file. Upon patient selection, the claim's LOB field and billing/rendering provider
fields (optional) will be populated automatically from information on-file in the patient
record.
When checked, the cursor (focus) will be forced to the Patient PCN field when a
new Professional claim is created. Upon patient selection, the claim's LOB will be
assigned automatically from the primary payer's LOB specified on the patient
record. The claim's billing provider and rendering provider will also be populated
automatically, if they have been specified on the patient record.
When unchecked, the cursor (focus) will be positioned normally on the LOB field.
The user is expected to enter or select the desired LOB and Billing Provider for the
new claim.
Auto-populate zero service line Units value to 1 during Professional claim entry –
Enables or disables auto-population of the service line "Units" value to one (1) during
Professional claim entry. This auto-population will occur when the user exits the "24d –
Procedure Code" field only if the "Units" value is currently zero.
When checked, the service line "Units" value will be initialized to "1" (if currently
zero) when the service line's procedure code is entered.
When unchecked, the service line "Units" value will not be initialized, and must
always be entered by the user if a non-zero value is desired.
Skip over line item Service Thru Date field during Institutional claim entry – Controls
whether or not the "Service Thru Date" field on the Institutional claim service line is include
in the forward tab sequence.
When checked, the service line "Service Thru Date" field will not be included in the
forward tab sequence, unless a date is already present in this field. Hand-key users
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who are accustomed to a single line item service date field may prefer to skip the
Service Thru Date field when entering claims.
When unchecked, the service line "Service Thru Date" field will be included in the
forward tab sequence.
Use the Physician reference file for Professional purchased services lookups –
Controls the source reference file for line-level Purchased Services provider lookup
operations during Professional claim entry.
When checked, all line-level Purchased Services provider lookups are performed
from the Physician reference file.
When unchecked, all line-level Purchased Services provider lookups are performed
from the Facility reference file.
Include only Revenue Codes with non-zero charge amounts in lookups – Determines
which Revenue Codes will be included in the lookup list during Institutional claim entry.
Consider enabling this option if most claims are to be hand-keyed and the Revenue Code
charge amounts for most of the codes to be billed have been setup in advance.
When checked, revenue code lookups will include only those Revenue Codes for
which a non-zero charge amount has been setup.
When unchecked, revenue code lookups will include all valid Revenue Codes
regardless of whether or not a charge amount has been setup.
Enable service line Total Charges auto-calculations during Institutional claim entry
– Controls whether or not the Institutional claim's service line "Total Charges" field will be
automatically recalculated when appropriate in response to changes in the "Rate" and/or
"Units" field values.
When checked, the service line "Total Charges" field will be automatically
recalculated when appropriate in response to changes in the "Rate" and/or "Units"
field values.
When unchecked, changes to other fields on the service line will not impact the
"Total Charges" field value.
Use Windows Notepad instead of built-in previewer to view response reports –
Controls whether the various ANSI response reports (ANSI-271, ANSI-277, ANSI-277CA
and ANSI-997/999) are to be displayed using the built-in previewer or Windows Notepad.
When checked, the response reports will be displayed using Windows Notepad.
When unchecked, the response reports will be displayed using the built-in
previewer.
Prompt to include only rejected claims in the Claim Ackkowledgment (277CA)
reports – Controls whether or not to prompt the user to include either all claims or only
rejected claims when printing Claim Acknowledgment (ANSI-277CA) reports.
When checked, prompts the user with the choice to include only rejected claims in
the report.
When unchecked, includes all claims in the report without prompting the user.
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Claim List Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The Claim List Preferences tab allows the user
to customize the Institutional & Professional Claim List form column configurations. Columns
are configured separately for the Institutional Claim List form and Professional Claim List form.
In addition, unique column configurations exist for each of the primary claim locations - "to be
transmitted" (CL), "transmitted" (TR), and "paid/history" (PD).
If your installation is licensed for both Institutional and Professional claim activities, then you
will need to select the appropriate claim type from the "Institutional Claim List" or
"Professional Claim List" radio buttons near the top of this tab. If your installation is licensed
for only one claim type, then this selection option will not be visible.
Select the second-level tab for the desired primary claim location - CL, TR, or PD. The various
controls on this tab will be populated with the current column configuration for the selected
location.
The remaining controls on this tab include:
The "Available Fields" listbox contains the names of all fields that are available for
selection.
The "Selected Fields" listbox contains the names of all fields that are currently configured
for the selected claim type and claim location. The order in which the Selected Fields are
listed represents the order in which they will be displayed on the Claim List form (from leftto-right).
The ">" and "<" buttons located between the listboxes move fields to/from the Selected
Fields list, respectively. To add a field to the current column configuration, just select the
field from the "Available Fields" listbox and click the ">" button. To remove a field, select
the desired field in the "Selected Fields" listbox and click the "<" button.
The Up/Down Arrow buttons allow the user to order the fields in the "Selected Fields"
listbox as desired. Simply select a field and click the up or down arrow to reposition the
field in the list.
The "Width" and "Heading" fields specify the column width and heading caption for the
currently selected field in the "Selected Fields" listbox. The default width and heading are
usually acceptable, but the user may change these if desired. The width values are in
approximate character increments.
Note: This customization feature may not be available in all installations. If the Claim
List Preferences tab is visible, then the feature is supported.
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Claim Import Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The Claim Import Preferences tab allows the
user to select the processing method used to import claim files from an up-stream system or
other external source. These preferences can be defined independently for Institutional and
Professional claim types.
If your installation is licensed for both Institutional and Professional claim activities, then you
will need to select the appropriate claim type from the "Institutional Claim Import" or
"Professional Claim Import" radio buttons near the top of this tab. If your installation is
licensed for only one claim type, then this selection option will not be visible.
Claim Import Processing Method - specifies the preferred claim import method. The
following claim import methods are available:
Import claims from print file using standard PrintLink mapping technique Import claims from a print image file using our advanced PrintLink mapping technique.
This is the default claim import method in most installations.
Import claims directly from pre-built file in intermediate delimited format - Import
claims directly from a pre-built file in intermediate delimited format. This method
bypasses the PrintLink translation step for facilities that can produce the intermediate
format file directly from an upstream system.
Import claims from file in Electronic Media Claims (EMC) format - Import claims
directly from a file in Electronic Media Claims (EMC) format. This method may be
used in facilities where the upstream system can generate a reliable EMC output file.
Claim Import Preprocessor - specifies an optional external "preprocessor" program to
be called prior to claim import processing. This preprocessor may be an executable
program or a DOS batch file (with associated PIF file). The PC-ACE Pro32 import code
will launch this preprocessor automatically and wait for completion before continuing with
import processing. Claims preprocessing can be performed with any of the 3 claim import
methods.
Note: Your distributor may have already configured these claim import settings. The
distributor can determine which settings (if any) a user can modify. Therefore, some or
all of the controls may be disabled.
Attention: You should modify these claim import settings only under the supervision of
your distributor or a technical support specialist. Incorrectly configuring these options
will render the claim import feature non-functional.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Importing claims" topic for a detailed description of the claim import methods
and optional preprocessor.
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Printing Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The Printing Preference tab allows the user to
specify options to control the printing of Institutional and Professional claim activity reports,
claim forms, and claim attachments.
If your installation is licensed for both Institutional and Professional claim activities, first select
the appropriate claim type from the "Institutional Printing Options" or "Professional
Printing Options" radio buttons near the top of this tab. If your installation is licensed for only
one claim type, then this selection option will not be visible.
The printing options are organized in a series of nested tabs as follows:
Import - settings on this tab control the printing of claim import reports. These include:
Automatically print claim import reports on completion - specifies whether claim
import reports will be printed automatically.
When checked, the claim import reports automatically print after the claim import
operation has completed.
When unchecked, the claim import reports will not print automatically. You will still
have the option to print the reports manually.
Print claim import rejection report even when all claims accepted - specifies
whether empty claim import rejection reports will be printed automatically. This option
is only enabled if you have chosen to print claim import reports automatically.
When checked, the claim import rejection report automatically prints even if there
are no rejected claims.
When unchecked, the import claim rejection report will not automatically print if it
is empty.
Import Report Printer - specifies the claim import reports printer.
Sort and subtotal claim import report by LOB and Payer ID - controls the sort
order and subtotaling method used for claim import reports.
When checked, the claim import report will be presorted by LOB and Payer ID,
and the resulting report will be subtotaled by LOB/Payer (and by Provider ID
within each LOB/Payer group).
When unchecked, claims will be be listed in the order they appear in the imported
file, and no subtotaling will be performed.
Report claims for each LOB/Payer on a separate page - controls the page break
method used for claim import reports. This option is only available when sorting the
import report in LOB/Payer order.
When checked, the claim import reports will break to a new page prior to printing
the first claim for each unique LOB/Payer combination. Enable this option to
insure that imported claims for each LOB/Payer combination are printed on
separate pages.
When unchecked, the claim import reports will be printed in a continuous fashion,
with no forced page breaks.
Process - settings on this tab control the printing of claim processing reports. These
include:
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Automatically print claim process reports on completion - specifies whether claim
processing reports will be printed automatically.
System Preferences
When checked, the claim processing reports automatically print after the claim
processing operation has completed.
When unchecked, the claim processing reports will not print automatically. You
will still have the option to print the reports manually.
Print claim process error report even when no errors exist - specifies whether
empty processing error reports will be printed automatically. This option is only
enabled if you have chosen to print claim processing reports automatically.
When checked, the claim processing error report automatically prints even if all
processed claims were clean.
When unchecked, the claim processing error report will not automatically print if it
is empty.
Process Report Printer - specifies the claim processing reports printer.
Include error details on process error report - specifies whether detailed edit
validation error descriptions are to be included in the processing error report by
default. This default value can be overridden for each processing run if desired.
When checked, the processing error report will include edit validation error
descriptions for each claim by default.
When unchecked, the processing claim report will not include edit validation error
descriptions.
Maximum number of process errors reported per claim - specifies the maximum
number of processing edit validation errors to be reported per claim. The default value
of 5 errors per claim helps to limit the size of the processing error report. Increase this
value substantially if you prefer that all errors be included in the report.
Prepare - settings on this tab control the printing of claim prepare reports. These include:
Automatically print claim prepare reports on completion - specifies whether claim
prepare reports will be printed automatically.
When checked, the claim prepare reports automatically print after the claim
prepare run has completed.
When unchecked, the claim prepare reports will not print automatically. You will
still have the option to print the reports manually.
Print claim prepare error report even when no errors exist - specifies whether
empty claim prepare error reports will be printed automatically. This option is only
enabled if you have chosen to print claim prepare reports automatically.
When checked, the claim prepare error report automatically prints even if all
claims were successfully prepared.
When unchecked, the claim prepare error report will not automatically print if it is
empty.
Prepare Report Printer - specifies the claim prepare reports printer.
Report claims for each LOB/Payer on a separate page - controls the page break
method used for claim prepare reports.
When checked, the claim prepare reports will break to a new page prior to printing
the first claim for each unique LOB/Payer combination. Enable this option to
insure that prepared claims for each LOB/Payer combination are printed on
separate pages.
When unchecked, the claim prepare reports will be printed in a continuous
fashion, with no forced page breaks.
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Claim Form - settings on this tab control printing of Institutional and Professional claim
forms and claim attachments. These include:
Default Printer - specifies the default claim form printer. This default selection may be
overridden when the claim form is printed.
Default Method - specifies the default claim form printing method. This method may
be overridden when the claim form is printed. The available printing methods include:
Pre-printed Forms - specifies the traditional printing method requiring preprinted CMS-1450/1500 claim forms.
Image Overlay - specifies an advanced overlay technique in which both the
claim form graphics and claim data are printed on stock paper. This method
requires the Adobe Acrobat Reader, and will only be enabled if this reader is
properly installed on the client workstation. Refer to the "Printing claims" topic
for more information on this advanced printing technique.
Pre-printed Claim Form Options - specifies page positioning adjustment settings for
printing claims using the pre-printed forms method. These settings allow the user to
adjust the top and left margins (in 1/100 inch increments) as well as the character font
(point) size.
Default Form Version – specifies the default claim form version. This selection may
be overridden when the claim form is printed. The available claim form versions
include:
Traditional CMS-1450 (UB92) Format – the standard Institutional claim form for
many years. This format will become obsolete when the National Provider ID (NPI)
rollout is complete.
Enhanced CMS-1450 (UB-04) Format – the enhanced Institutional UB-04 claim
form capable of reporting the National Provider ID (NPI) for the claim's Billing
Provider and Attending, Operating and Other Physicians. Increases the number of
Condition, Occurrence, Occurrence Span and Value codes that can be reported
and adds several miscellaneous fields.
Traditional CMS-1500 Format – the standard Professional claim form for many
years. This format will become obsolete when the National Provider ID (NPI) rollout
is complete.
Enhanced CMS-1500 Format (Aug 2005) – the enhanced Professional claim form
capable of reporting the National Provider ID (NPI) for the claim's Billing,
Rendering and Referring Providers.
Print with Payer Description (Payer Source Code / Payer ID) - specifies whether to
include the Payer Source Code and/or Payer ID values when printing the Payer
Description. The selected values are printed to the left of the Payer Description.
When checked, the Payer Source Code or Payer ID will be printed to the left of
the Payer Description.
When unchecked, the Payer Source Code or Payer ID will not be printed with the
Payer Description.
Print decimal point on all dollar amount fields - specifies whether to print the
decimal point on all currency fields. When printing forms, it is often desirable to omit
the decimal point.
When checked, the decimal point will be printed on all currency fields.
When unchecked, the decimal point will not be printed on currency fields.
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System Preferences
Print the signature block date by default (Institutional, UB92 form only) - specifies
whether the Institutional claim form signature block date is to be printed automatically
by default. This default setting can be overridden when a claim is printed.
When checked, the current system date will be printed automatically by default in
the claim form signature block. An alternate date (or no date at all) may be
specified instead when a claim is printed.
When unchecked, the claim form signature block date will be left blank by default.
Print today's date as line 23 creation date (Institutional, UB-04 form only) - specifies
whether to print the current date by default in the Creation Date field on the
Institutional claim form's 23rd service line. This default setting can be overridden when
a claim is printed.
When checked, the current system date will be printed automatically by default in
the Creation Date field. An alternate date may be specified instead when a claim
is printed.
When unchecked, the standard method for determining the Creation Date will be
used by default. The prepare date will be printed for transmitted claims. The entry
date will be printed for claims pending transmission.
Override the provider signature block date by default (Professional only) specifies whether to print the provider "signature on file" date from the Professional
Claim Form, or to instead allow the user to override the signature block date by
default. This default setting can be overridden when a claim is printed.
When checked, the provider "signature on file" date on the Professional Claim
Form will be ignored by default during claim printing. An alternate date (or no date
at all) may be specified instead when a claim is printed.
When unchecked, the provider "signature on file" date on the Professional Claim
Form will be printed by default to the claim form signature block.
Print line items using single spacing when appropriate (Professional only) specifies whether single spacing of line items is to be used when appropriate on
Professional claim forms. The standard Professional form layout implies that doublespacing is to be used by default.
When checked, all Professional claims containing more than 6 line items will be
printed with the line items single-spaced. This technique accommodates up to 11
line items per claim form page.
When unchecked, all Professional claims will be printed using the standard preprinted form line item spacing (6 line items per page).
Print claim attachments by default (Professional only) - specifies whether
Professional claim attachments should be printed by default. This default setting can
be overridden when a claim is printed if desired.
When checked, any existing claim attachments for the selected claim(s) will be
printed by default.
When unchecked, no claim attachments for the selected claim(s) will be printed by
default.
Print all claim attachments at the end of multiple-claim print run when
appropriate - specifies whether claim attachments should be printed as a group at the
end of a multiple-claim print session.
When checked, claim attachments will be printed as a group following the printing
of all selected claims when using the pre-printed form method. You will be
prompted to load stock paper in the printer prior to claim attachment printing.
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When unchecked, claim attachments for each claim will always be printed
immediately following the associated claim.
Tip: Checking this option will typically result in the most reasonable approach to
printing claim attachments. The system will print attachments immediately
following the associated claim form unless the pre-printed forms method is being
used.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Printing claims" topic for more information on the "pre-printed" versus "image
overlay" techniques.
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System Preferences
Data Communication Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The Data Communication Preferences tab
includes settings to control the PC-ACE Pro32 data communications interface. PC-ACE Pro32
can be configured to launch external data communications programs or scripts to perform
electronic claim file transfers or other data communication related operations.
The identical "Option" tabs correspond to each of the available launch buttons on the Data
Communications Options form. The controls on each tab include:
Option N Program - specifies the complete path and filename of the program or batch file
(with corresponding Windows PIF file) to be launched.
Tip: Use the convenient "browse" button adjacent to this control to easily locate and
retrieve the full path of the desired program or batch file. Enclose paths that contain
spaces (i.e., Windows long file and directory names) in double-quotes to ensure
proper launch interpretation.
Button Caption - specifies the desired button caption text.
Tip: Use a single "&" character in the button caption to define a windows shortcut key.
Place the "&" character immediately before the desired shortcut character.
Once a valid program/script path and button caption are defined on any of these tabs, the
corresponding launch button will be enabled on the Data Communications Options form.
Note: Your distributor may have already configured these data communication launch
paths and captions. The distributor can determine which data communications settings
(if any) a user can modify. Therefore, some of the tabs/controls may be disabled or
even hidden.
Attention: You should modify these data communications settings only under the
supervision of your distributor or a technical support specialist. Incorrectly configuring
these options will render the data communications feature non-functional.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Transmitting electronic claim files" topic for more information on a typical
application of the PC-ACE Pro32 data communications launch capabilities.
Refer to the "Data Communications File Maintenance" topic for information on configuring
data communications parameters and the Data Communications Control File.
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Miscellaneous Preferences
PC-ACE Pro32 preference settings are organized on a tabbed dialog accessible from the PCACE Pro32 Main Toolbar's main "File" menu. The Miscellaneous Preferences tab includes
the following maintenance and configuration settings:
Purge archived EMC transmission files after "NN" days - specifies whether archived
Institutional and Professional EMC transmission files are to be automatically purged by the
system. If automatic purging is enabled, specifies the number of days EMC files are to be
retained.
When checked, all EMC transmission files older than the specified number of days
will be automatically purged from the transmission file archive.
When unchecked, all EMC transmission files will remain archived until manually
deleted. Refer to the "Reactivating previously transmitted claims" topic for more
information on maintaining the transmission file archive.
Purge archived ANSI-997 acknowledgment files after "NN" days - specifies whether
archived Institutional and Professional ANSI-997/999 transmission acknowledgment files
are to be automatically purged by the system. If automatic purging is enabled, specifies
the number of days the acknowledgment files are to be retained.
When checked, all ANSI-997/999 transmission acknowledgment files older than the
specified number of days will be automatically purged from the acknowledgment file
archive.
When unchecked, all ANSI-997/999 transmission acknowledgment files will remain
archived until manually deleted. Refer to the "Viewing and maintaining transmission
acknowledgment files" topic for more information on maintaining the
acknowledgment file archive.
Note: If this preference option is disabled, support for ANSI-997/999 transmission
acknowledgment files is not available on your installation.
Purge archived ANSI-277 claim status response or ack files after "NN" days specifies whether archived Institutional and Professional ANSI-277 claim status response
and claim acknowledgment files are to be automatically purged by the system. If automatic
purging is enabled, specifies the number of days the response files are to be retained.
When checked, all ANSI-277 claim status response and claim acknowledgment files
older than the specified number of days will be automatically purged from the
response file archive.
When unchecked, all ANSI-277 claim status response and claim acknowledgment
files will remain archived until manually deleted. Refer to the "Viewing and
maintaining claim status response and acknowledgment files" topic for more
information on maintaining the response file archive.
Note: If this preference option is disabled, support for the ANSI-276/277 claim
status request/response feature is not available on your installation.
Purge archived ANSI-271 eligibility benefit response files after "NN" days - specifies
whether archived Institutional and Professional ANSI-271 eligibility benefit response files
are to be automatically purged by the system. If automatic purging is enabled, specifies
the number of days the response files are to be retained.
When checked, all ANSI-271 eligibility benefit response files older than the specified
number of days will be automatically purged from the response file archive.
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System Preferences
When unchecked, all ANSI-271 eligibility benefit response files will remain archived
until manually deleted. Refer to the "Viewing and maintaining eligibility benefit
response files" topic for more information on maintaining the response file archive.
Note: If this preference option is disabled, support for the ANSI-270/271 eligibility
benefit request/response feature is not available on your installation.
Purge claim activity log after "NN" days - specifies whether the Institutional and
Professional claim activity logs will be automatically maintained by the system. If
automatic maintenance is enabled, specifies the number of days that log entries are to be
retained.
When checked, the claim activity logs will be maintained to include only entries for
the specified number of days.
When unchecked, the claim activity logs will grow indefinitely until it they are purged
manually. Refer to the "Reviewing the claim activity logs" topic for more information
on the viewing and purging the claim activity logs.
Limit initial claim list display of transmitted/paid claims to most recent "NN" months
- specifies whether or not to limit the initial display of transmitted/paid claims in the
Institutional and Professional Claim List forms based on the claim's transmission date. If
this feature is enabled, specifies the number of months of the most recent claims to be
displayed by default.
When checked, only claims that have been transmitted (i.e., prepared) in the most
recent number of months, as specified, will be displayed by default when viewing
the transmitted/paid claim list locations (TR, PD and TR/PD).
When unchecked, all transmitted/paid claims in the database will be displayed by
default when viewing the transmitted/paid claim list locations (TR, PD and TR/PD).
Tip: To display transmitted/paid claims older than the specified number of months,
simply click the "Advanced Filter Options" button on the Claim List form and enter the
desired Transmit Date range.
Note: Limiting the number of transmitted/paid claims being displayed in the claim
list improves the list's responsiveness. Claim list performance improvements should
be particularly noticable when accessing the "TR", "PD" and "TR/PD" locations on
networked installations with large active claims databases. If this preference option
is disabled, support for this feature is not available on your installation.
Adobe Acrobat Reader - specifies the complete path for the Adobe Acrobat Reader
program (ACRORD32.EXE) required for printing claims using the "image overlay" method.
When the Acrobat Reader is properly installed, PC-ACE Pro32 will automatically detect
and configure this path. The Adobe Acrobat Reader is available for download from Adobe
(http://www.adobe.com). Refer to the "Printing claims" topic for more information on
printing claim forms and attachments.
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Common Claim Activities
Adding a new claim
New claims can be added to PC-ACE Pro32 using any of these techniques:
Import the claims from a print file or other supported source. See the "Importing claims"
topic for more details.
Click the "Enter Claims" button on the Claims Menu form (Institutional or Professional) to
enter claims manually. The system will automatically create and display new empty claims
in succession until a claim is cancelled. Use this technique to enter multiple claims in a
single session.
Click the "New" button on the Claim List form (Institutional or Professional) to enter a
single claim manually. The new claim will automatically be selected in the list when it is
saved.
Claims are manually entered on the "Institutional Claim Form" or "Professional Claim Form".
The data fields are typically entered in the order presented - from left-to-right and top-to-bottom
- on each tab of the claim form. Edit validation errors may be encountered during this entry
process if the data entered violates any of the predefined edits for the specific claim type.
Correct any such edit errors and click the "Save" button to save the claim. Claims containing
unresolved edit errors may be saved if desired by clicking either the "Save With Errors" button
(visible if only non-fatal errors exist) or "Save With Fatal" button (visible if any fatal errors
exist). Only one of these buttons will be visible at any given time. If neither button is visible,
then fatal errors exist on one or more key claim fields. These fatal edit errors must be
corrected before the claim can be saved.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Institutional & Professional Claims Menus" topic for more information about
the Claims Menu form.
Refer to the "Claim List Form Features" topic for details on using the Claim List form.
Refer to the "Institutional Claim Form" and "Professional Claim Form" topics for more
information on using the Institutional and Professional claim forms.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
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Listing, modifying and maintaining claims
Claims in PC-ACE Pro32 are listed, modified, and otherwise maintained from the Institutional
& Professional Claim List forms. The Claim List form operation is identical for Institutional and
Professional claim types. To access the Claim List form:
1) Click either the "Institutional Claims Processing" or "Professional Claims Processing"
button on the PC-ACE Pro32 Main Toolbar to display the respective Claims Menu form.
2) From the Institutional or Professional Claims Menu form, click the "List Claims" button to
open the respective Claim List form.
Most actions to be performed on a claim may be executed from the Claim List form. Claims
can be created, viewed/modified, copied, deleted/undeleted, purged, reactivated,
held/released, printed, and archived/unarchived from the list. In addition, payments may be
posted to a selected claim from the Claim List form. Refer to the "Claim List Form Features"
topic for complete details on the features and operation of the powerful Claim List form.
Viewing & Modifying Claims
Viewing and/or modifying existing claims from the Claim List form can be performed with these
general steps:
1) Use the Claim List form's powerful sorting and filtering capabilities to locate the claim of
interest in the list.
2) Select the desired claim in the list and click the "View/Update" button to display the claim
details in the appropriate claim form. Alternatively, just double-click the desired claim record
in the list.
3) Make all desired changes to the claim. Refer to the Institutional Claim Form or Professional
Claim Form topics for details on the many productivity enhancing features available on
these powerful claim forms.
4) When all changes have been made, click the "Save" button to save the claim record and
close the form. Review and correct any edit validation errors as needed. Alternatively, click
the "Cancel" (or "Close") button to cancel any pending claim changes.
Actions On Multiple Claims
Many of the claim actions available in the Claim List form are applicable to both single
(selected) claims as well as groups of "checked" claims. This powerful multi-selection
capability makes operating on groups of claims a snap! Simply use the Claim List form's
advanced filtering options to narrow the claim list contents down until it contains only the
desired claims. Then select the "Check All Claims" action from the main or popup menu to
instantly mark (i.e., "check") all the claims of interest. A number of actions are available from
the main or popup menu to operate on the entire group of claims in a single session. Refer to
the "Claim List Form Features" topic for complete details on selecting and acting on multiple
claims at once.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Claim List Form Features" topic for details on using the Claim List form.
Refer to the "Institutional Claim Form" and "Professional Claim Form" topics for more
information on using the Institutional and Professional claim forms.
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Common Reference File Procedures
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
Refer to the on-line help "Common Claim Activities" folder for hyperlinks to other claimrelated topics of interest.
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Importing claims
Claims are introduced into PC-ACE Pro32 by either entering them manually or by importing
them from an external source. The claim import method is ideal for facilities that maintain their
claims in an upstream claims management system. Using our versatile claim import
capabilities, these claims can be quickly and accurately loaded into the PC-ACE Pro32
database for subsequent processing, preparation, and transmission. Three external claim
import sources are supported:
Print Image (PrintLink) - Using PC-ACE Pro32's advanced PrintLink mapping technique,
claims can be imported from print image files produced by your upstream system. This is
the default claim import method in most installations.
Intermediate Delimited Format - Claims can be imported directly from a pre-built file in
"intermediate delimited" format. This internal delimited ASCII format is the same as that
produced by the PrintLink translator in the "print image" import technique. This claim
import method provides a more versatile solution for facilities that can produce the
intermediate format file directly from an upstream system.
Electronic Media Claims (EMC) Format - Claims can be imported directly from a file in
Electronic Media Claims (EMC) format. This method may be used in facilities where the
upstream system can generate a reliable EMC output file. PC-ACE Pro32 currently
supports UB92 Version 5.0, UB92 Version 6.0, and ANSI-837 file formats for Institutional
claims. Professional claim import formats include NSF 1.04 thru NSF 3.01 and ANSI-837.
Attention: Support for the listed import formats varies among PC-ACE Pro32
distributors. Check with your software distributor first if you intend to import claims into
the product. Fee-based support from Medlink Technologies, Inc. may also be available
for import formats which are not being supported by your software distributor.
Refer to the "Claim Import Preferences" topic to select the desired claim import method and
configure the optional preprocessor (described later in this topic).
Attention: You should modify these claim import settings only under the supervision of
your distributor or a technical support specialist. Incorrectly configuring these options
will render the claim import feature non-functional.
Getting Ready To Import Claims
Some preparation is required before claims can be imported into PC-ACE Pro32. Certain
preparation steps need only be performed once, while others must be performed each time a
new set of claims is to be imported. The preparation steps required for each claim import
method are listed below. You need only be concerned with the preparation steps for your
selected claim import method.
Print Image (PrintLink) - importing claims using the PrintLink method requires the
following preparation:
1)
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Perform all required "once-only" preparation steps for importing claims using the
PrintLink method. Complete these steps as part of the initial PC-ACE Pro32 system
setup described in either the "Setup of Medicare Part A Systems", "Setup of
Institutional All-Payer Systems", or "Setup of Professional Systems" topic. In
summary, this "once-only" setup consists of:
Common Reference File Procedures
Performing PrintLink mapping on a sample print file to generate the
corresponding "map" file. Copying the map file to the server's claim import
directory.
Confirming that the correct "map control" file has been placed in the server's
claim import directory.
Tip: Check with your distributor before performing these "once-only" setup
steps. Some distributors build this setup into the program installation
procedure.
2)
Copy the print file to be imported into the server's claim import directory. The print
file must be named as defined in the corresponding print "map" file. The claim
import directory is named "winpcace\impub92" for Institutional claim import
operations and "winpcace\imp1500" for Professional claim import operations.
Attention: Windows long filenames are partially supported for the PrintLink
import method map and print files. The map filename may contain space
characters, periods, underscores, and most other characters permitted in long
filenames under Windows. However, the parenthesis characters "(" and ")" are
not allowed in the map filename. The print filename must not contain
parenthesis or space characters. Use the underscore "_" character instead of
the space character when naming the print file.
Intermediate Delimited Format - importing claims using the intermediate delimited
format method requires the following preparation:
1)
Perform all required "once-only" preparation steps for importing claims using the
intermediate delimited format method. Complete these steps as part of the initial
PC-ACE Pro32 system setup described in either the "Setup of Medicare Part A
Systems", "Setup of Institutional All-Payer Systems", or "Setup of Professional
Systems" topic. In summary, this "once-only" setup consists of:
Confirming that the correct "map control" file has been placed in the server's
claim import directory.
Tip: Check with your distributor before performing these "once-only" setup
steps. Some distributors build this setup into the program installation
procedure.
2)
Generate the intermediate format file containing the claims to be imported.
3)
Copy the intermediate format file to be imported into the server's claim import
directory. The intermediate format file must be named "plink.out". The claim import
directory is named "winpcace\impub92" for Institutional claim import operations
and "winpcace\imp1500" for Professional claim import operations.
Electronic Media Claims (EMC) Format - importing claims using the EMC format
method requires the following preparation:
1)
Perform all required "once-only" preparation steps for importing claims using the
EMC format method. Complete these steps as part of the initial PC-ACE Pro32
system setup described in either the "Setup of Medicare Part A Systems", "Setup of
Institutional All-Payer Systems", or "Setup of Professional Systems" topic.
Tip: Check with your distributor before performing these "once-only" setup
steps. Some distributors build this setup into the program installation
procedure.
2)
Generate the EMC format file containing the claims to be imported.
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3)
Copy the EMC format file to be imported into the server's claim import directory. The
file must have a ".dat" file extension (e.g., "EMC192.DAT"). The claim import
directory is named "winpcace\impub92" for Institutional claim import operations
and "winpcace\imp1500" for Professional claim import operations.
Note: Windows long filenames are supported for the EMC Format claim import
method.
Once these preparation steps are complete, you are ready to import the claims into PC-ACE
Pro32.
Importing the Claims
Once the preparation steps are complete, importing claims into PC-ACE Pro32 is quick and
simple. The following steps outline the claim import process:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
2) Click the "Import Claims" button on the Claims Menu form to open the Institutional or
Professional Claim Import form. The form's caption should reflect the chosen claim import
method.
3) If you are using the PrintLink claim import method, and you have multiple "map" files in the
server's claim import directory, you will see a drop-down list labeled "Select PrintLink Map
File". Select the map/print file to be imported from this list. If you are using the PrintLink
claim import method, but only one map file is defined, this drop-down list will not be visible.
If you are using the Intermediate Delimited Format claim import method, the system
assumes that the file to be imported has already been placed in the claim import directory.
This file must be named "plink.out".
If you are using the Electronic Media Claims (EMC) File claim import method, and you
have multiple EMC files in the server's claim import directory with ".dat" extensions, you
will see a drop-down list labeled "Select EMC File". Select the EMC file to be imported
from this list. If you are using the EMC File claim import method, but only one EMC file is
present in the claim import directory, this drop-down list will not be visible.
4) Click the "Import" button to initiate the claim import operation. As the import proceeds,
running totals of the count and dollar value of all "imported" and "rejected" claims are
displayed on the Claim Import form. You will be notified when the claim import operation
completes.
Note: Claims are rarely rejected during import into PC-ACE Pro32. The most
common reason for rejecting a claim is that the claim is a duplicate of an existing
"unprocessed" (UNP) claim in the "to be transmitted" (CL) location. This can
sometimes occur if the same file is inadvertently re-imported into the system.
5) If desired, click the "View Results" and/or "View Rejects" buttons to view the accepted and
rejected claim reports, respectively. These reports can be printed from the report previewer
if desired.
Tip: Refer to the "Printing Preferences" topic for information on configuring claim
import reports to be printed automatically or to a specific printer.
6) When you have completed your review of the claim import reports, click the "Close" button
on the Claim Import form. You may now proceed to process the imported claims
automatically or work the claims one-by-one from the Claim List form.
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Optional Import Preprocessor Feature
Additional claim import flexibility is available with PC-ACE Pro32's optional import
"preprocessor" feature. A user-developed executable program or a DOS batch file (with
associated PIF file) can be configured for execution prior to standard claim import processing.
The PC-ACE Pro32 import sequence will launch this preprocessor automatically and wait for
completion before continuing with standard import processing. The preprocessor might simply
copy a print image file from one directory to another. Alternatively, it might perform a complex
data translation operation to generate the supported claim import file. Claims preprocessing
can be performed with any of the 3 claim import methods described above. See the "Claim
Import Preferences" topic for information on configuring a claim import preprocessor.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Claim Import Preferences" topic to select the desired claim import method
and configure the optional preprocessor.
Refer to the "Processing claims automatically" topic to learn how the imported claims can
be processed automatically.
Refer to the "Printing Preferences" topic for information on claim import report options
(automatic printing, printer selection, etc.).
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Reversing the most recent claim import run
On occasion, it may become desirable to "reverse" the most recent claim import operation. In
other words, to remove the imported claims from the database as if they had never been
imported in the first place. Possible scenarios that might give rise to this requirement include:
A partially corrupted print file resulted in an incomplete claim import run. The print file
has been repaired and it is desirable to perform the import again from the beginning.
The PrintLink map file had a minor mapping error that resulted in the truncation of the
first character of a specific data field on every claim. The map file has now been
corrected and the original print file is to be re-imported.
The same claim file was inadvertently imported more than once.
Follow the steps below to reverse the most recent claim import run:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
2) From the Claims Menu form, select the main menu "Maintain" and "Reverse Claim
Import" items to display the Claim Import Reversal Utility form.
3) Select the "Reverse most recent claim import operation" radio button and click the
"Continue" button to proceed. The Claim Import Reversal Confirmation form will be
displayed, containing a list of all claims imported in the most recent run.
Note: If the "Reverse most recent claim import operation" radio button is
disabled, the system cannot determine the specific details of the most recent claim
run. Also notice the "Delete all unprocessed claims for date range" radio button,
which provides an alternate technique for selectively deleting unprocessed claims by
date range.
4) Click the "Check All Claims" button to mark all claims from the previous claim import run
for deletion. Click the "Delete Checked Claims" button to perform the deletion.
Attention: Claims can only be "reversed" if they remain "unprocessed" (i.e., their
claim status = "UNP"). Once a claim has been processed or materially changed, it is
no longer eligible for reversal. If any claims in the selected deletion list are no longer
eligible for reversal, you will receive a notification message for each such claim.
These ineligible claims must be located and deleted manually from the Claim List
form.
5) When the reversal operation completes, the Claim Import Reversal Confirmation form will
close automatically.
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Processing claims automatically
Claim "processing" in PC-ACE Pro32 refers to the application of a specific set of edit
validation rules to the claim. A processed claim is pronounced as either "clean", "contains nonfatal errors", or "contains fatal errors". This claim is assigned a status code of "CLN", "ERR", or
"ERF", respectively, to indicate the state of the processed claim.
In addition to processing (or "working") claims one-by-one from the Claim List form, PC-ACE
Pro32 also provides an automatic processing function that can sequentially process all (or a
filtered selection of) unprocessed claims in the "to be transmitted" (CL) location. Automatic
claim processing is an ideal way to quickly work a batch of imported claims. Once automatic
processing has completed, the user can focus attention only on the claims with errors - greatly
improving user productivity. To process claims automatically, follow these simple steps:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
2) From the Claims Menu form, click the "Process Claims" button to open the Automated
Claim Processing form. This form provides the following processing options:
Claim Filter Parameters - claims must meet all specified filter criteria to be considered
for automatic processing.
LOB - specifies a single line of business (LOB) to be considered. Only claims with
this LOB will be eligible for automatic processing. Leave this field empty to include
claims for any line of business.
TOB (Institutional only) - specifies a single type of bill (TOB) to be considered.
Only claims with this TOB (first 2 characters only) will be eligible for automatic
processing. Leave this field empty to include claims for all bill types.
Provider - specifies one or more Provider IDs to be considered. Only claims for
the specified provider(s) will be eligible for automatic processing. Leave this field
empty to include claims for all providers. If multiple Provider ID values are
specified, claims for any of the specified providers will be included. Separate
multiple Provider ID values with a semi-colon. For Institutional claim processing,
the specified Provider ID value(s) will be compared to the claim's Provider ID field
for the "submission" payer. For Professional claim processing, the specified
Provider ID value(s) will be compared to the claim's "billing" Provider ID.
Reprocess claims with errors - specifies whether or not claims in the "to be
transmitted" (CL) location that currently have a "has errors" (ERR) or a "has fatal
errors" (ERF) status are eligible for automatic processing. If this option is
unchecked, only "unprocessed" claims (UNP) will be considered eligible.
Tip: Reprocessing claims with errors might be helpful, for example, after a
change is made to the edit validation rules. It is feasible that a group of claims
all failed the same ill-conceived edit validation rule, which has subsequently
been reviewed and changed.
Processing Options - options that control the automatic processing operation.
Present claims with errors for immediate editing - instructs the automatic
processing engine to pause each time a claim with errors is processed and to
present the claim for immediate consideration in the Institutional Claim Form or
Professional Claim Form. This is referred to as "interactive" processing mode.
When the user closes the claim form, the automatic processing run will resume
with the next claim in the sequence.
Include edit error details in process error report - instructs the automatic
processing engine to include the specific edit validation error descriptions in the
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compiled error report. Check this option when plan to research the specific edit
validation errors for each claim from this hardcopy report.
Tip: If you rarely refer to the specific edit validation error descriptions in the
error report, you can significantly speed up automatic processing by leaving
this option unchecked. This allows the edit engine to stop processing a claim
on the first detected error, since it is only important to know that the claim has
errors - not specifically which errors.
3) Specify the desired filter parameters (if any) and processing options. When ready, click the
"Process" button and confirm your intention to process the claims. Each eligible claim will
be processed in sequence. As the processing operation proceeds, running totals of the
count and dollar value of all "clean" claims and claims with "errors" are displayed on the
Automated Claim Processing form. You will be notified when the claim processing operation
completes.
Note: If you are processing claims in "interactive" mode, automatic processing will
be temporarily paused each time a claim containing errors is processed. The claim
will be automatically displayed in either the Institutional Claim Form or Professional
Claim Form with the Edit Validation Errors List form open to display the claim's edit
validation errors (unless disabled in the Preference settings). You can either work
the claim until it is clean, save the claim with errors, or cancel the claim to leave it
unprocessed. Once you have closed the claim form, the automatic processing run
will continue with the next eligible claim in the sequence.
Tip: A convenient "Cancel Run" button will be available on the Institutional Claim
Form or Professional Claim Form when processing claims in "interactive" mode. Click
this button to cancel the currently displayed claim and abort the automatic processing
run. The current claim and all remaining eligible claims will remain unprocessed.
4) If desired, click the "View Results" and/or "View Errors" buttons to view reports of the
clean claims and claims with errors, respectively. These reports can be printed from the
report previewer if desired.
Note: If you checked the "Include edit error details in process error report"
processing option, the claims with errors report will include the specific edit
validation errors reported for each claim (up to 5 per-claim maximum by default). If
this option was not checked, the claim reference will be reported without any
supporting edit validation error details.
Tip: Refer to the "Printing Preferences" topic for information on configuring claim
processing reports to be printed automatically or to a specific printer. You can also set
the maximum number of edit validation errors to be listed per claim.
5) When you have completed your review of the claim processing reports, click the "Close"
button on the Automated Claim Processing form. You may now proceed to work the
remaining unprocessed claims and claims with errors one-by-one from the Claim List form.
Attention: Claims containing non-fatal errors will be assigned a status of "unprocessed"
(UNP) during automatic processing, rather than the "has errors" (ERR) status that you
might expect. This is done to avoid inadvertently including these claims in a
subsequent prepare run (since "ERR" status claims can optionally be included in the
prepare). When you eventually work these claims, you can decide on an individual
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basis whether the claim should be corrected, transmitted with the non-fatal error(s), or
held pending further evaluation.
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Preparing claims for transmission
Claim "preparation" in PC-ACE Pro32 refers to the act of generating an Electronic Media
Claims (EMC) file suitable for transmission to your claims processor. This EMC file will contain
all relevant submission details for one or more processed claims. Only claims in the "to be
transmitted" (CL) location with an "electronic" (E) media setting are eligible for preparation.
When a claim is "prepared" into an EMC file, it is automatically moved to the "transmitted" (TR)
location. Residence in the "transmitted" (TR) location reflects its transmitted state and also
prevents the claim from being inadvertently retransmitted.
Note: Before preparing claims for the first time, you may need to setup your Submitter
reference file. This file contains important data that will be used to build the EMC file.
Separate submitter details exist for Institutional and Professional claim types. Since
some distributors pre-configure the Submitter reference file, you should check with
them before making any changes. Refer to the "Submitter File Maintenance" topic for
more information on configuring this important reference file.
To prepare claims in PC-ACE Pro32, follow these simple steps:
3) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
4) From the Claims Menu form, click the "Prepare Claims" button to open the Claim Prepare
For Transmission form. This form provides the following preparation options:
Claim Filter Parameters - claims must meet all specified filter criteria to be considered
for preparation.
LOB - specifies a single line of business (LOB) to be considered. Only claims with
this LOB will be eligible for preparation. Select the "<< All >>" item to include
claims for any line of business.
Note: The Submitter reference file supports LOB-specific setup information if
desired. Selecting a specific LOB for preparation will trigger the use of the
matching LOB-specific submitter information (if any). Refer to the "Submitter
File Maintenance" topic for more information on this advanced feature.
Payer - specifies a single Payer to be considered. Only claims being submitted to
the selected payer will be eligible for preparation. Select the "<< All Payers for
LOB(s) >>" item to include claims for all payers. Note: This selection is only
enabled when a specific LOB has been selected for preparation.
Note: The Submitter reference file supports Payer-specific setup information
if desired. Selecting a specific LOB and Payer for preparation will trigger the
use of the matching LOB/Payer-specific submitter information (if any). Refer
to the "Submitter File Maintenance" topic for more information on this
advanced feature.
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Provider - specifies one or more Providers to be considered. Only claims for the
selected provider(s) will be eligible for preparation. Select the "<< All Providers
for Payer(s) >>" item to include claims for all providers. For Institutional claim
preparation, the provider to be compared is the one associated with the claim's
"submission" payer. For Professional claim preparation, the provider to be
compared is the claim's "billing" provider. Note: This selection is only enabled
when a specific LOB and Payer have been selected for preparation.
Common Reference File Procedures
Note: Choose the "<< Selected Providers for Payer >>" item in the dropdown list to specify multiple Provider IDs. Enter any number of Provider IDs
(separated by semicolons) on the Multiple Provider Selection form. If multiple
providers are specified, claims for any of the specified providers will be
included. For your convenience, the system remembers the last multipleprovider filter string specified.
Prepare Options - options that control the claim preparation operation. Note: These
options may not be available on some systems.
Submission Status - specifies whether the EMC file should be designated as a
"production" or "test" submission. The initial state of this option is determined by a
Submitter reference file setting.
Include Error Claims? - specifies whether claims with "non-fatal errors" (Status =
"ERR") are to be eligible for preparation. When checked, all claims in the "to be
transmitted" (CL) location with a status or either "CLN" (clean) or "ERR" (contains
non-fatal errors) will be eligible for preparation. When unchecked, only clean
claims will be eligible for preparation. The initial state of this option is determined
by a Submitter reference file setting.
Attention: The default settings for these control options are typically configured
by your distributor. We recommend overriding these option settings only under
the instruction of your distributor or an authorized technical support specialist.
The distributor may restrict which of these prepare options you are permitted to
override.
5) Specify the desired filter parameters (if any) and preparation options. When ready, click the
"Prepare Claims" button and confirm your intention to prepare all eligible claims. As the
preparation operation proceeds, running totals of the count and dollar value of all prepared
claims will be displayed on the Claim Prepare For Transmission form. You will be notified
when the claim preparation operation completes.
Attention: Claim preparation requires exclusive system access. When you attempt
to prepare claims, you will be notified if exclusive system access cannot be granted
(i.e., other users are running PC-ACE Pro32). When this occurs, you should
instruct all users to exit the program before proceeding.
6) If desired, click the "View Results" and/or "View Errors" buttons to view reports of the
successfully prepare claims and rejected claims, respectively. These reports can be printed
from the report previewer if desired.
Note: Claims will rarely be rejected during the prepare operation. A claim will be
rejected, for example, if the "submission" payer specified on the claim is no longer
present in the Payer reference file. Rejected claims must be re-processed and
corrected before they can be successfully prepared.
Tip: Refer to the "Printing Preferences" topic for information on configuring claim
preparation reports to be printed automatically or to a specific printer.
7) When you have completed your review of the claim preparation reports, click the "Close"
button on the Claim Prepare For Transmission form. You may now proceed to transmit the
EMC file generated during this claim preparation session.
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Note: The prepared EMC file is located in the server's "winpcace" directory. The file is
named "bctrans.dat" for Institutional claims and "bstrans.dat" for Professional claims,
by default. This default naming convention may be overridden in the Submitter
reference file.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Submitter File Maintenance" topic for details on configuring the Submitter
reference file.
Refer to the "Transmitting electronic claim files" topic for more information on transmitting
the prepared EMC file.
Refer to the "Reactivating previously transmitted claims" topic to learn how transmitted
claims can be selectively reactivated for re-transmission.
Refer to the "Recovering from an interrupted claim prepare run" topic to see how PC-ACE
Pro32 can recover from an interruption in the preparation process.
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Transmitting electronic claim files
PC-ACE Pro32 interfaces seamlessly with third party communications packages to transmit
Electronic Media Claims (EMC) files. This approach assures maximum flexibility for the
distributor and eliminates any PC-ACE Pro32 dependencies. A convenient "launch" facility
makes it easy for the user to initiate file transmissions and other data communications
functions (terminal emulation sessions, for example). PC-ACE Pro32 may be configured to
launch any required data communications functions without exiting the program.
Before you are ready to transmit, you must have already entered (or imported and processed)
one or more claims, and prepared these claims into an EMC file suitable for transmission. Let's
assume your system has been configured to launch a data communications program that will
transmit the prepared EMC file to your claims processor. You can initiate this file transmission
with the following steps:
1) Complete the pre-transmit procedures provided by your distributor, if any.
2) From the PC-ACE Pro32 Main Toolbar, click the "Data Communications Functions"
button to open the Data Communications Options form. Each pre-configured data
communications function will be represented by one of the available "launch" buttons.
Tip: Only the pre-configured launch buttons will be enabled. These available buttons
may be presented on up to 3 distributor-defined tabs. If all buttons are disabled, then
your system has not been setup for any data communications functions. Refer to the
"Data Communication Preferences" topic for information on configuring these launch
buttons.
3) For this example, let's assume the first button is labeled "Transmit Claims" and is preconfigured to launch the EMC file transmission program. Your button labels and functions
may be different, but the launch procedure is basically the same. Simply click the "Transmit
Claims" button to initiate the transmission process.
Note: PC-ACE Pro32 only initiates (or launches) the third-party file transmission
program. It does not monitor the transmission program's progress, nor is it informed
of the transmission's completion status. All exception handling must be done by the
third-party data communications program or script (e.g., re-dial, restart on dropped
line, etc.).
4) Click the "Close" button on the Data Communications Options form when the file
transmission has completed.
5) Complete the post-transmit procedures provided by your distributor, if any.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Reactivating previously transmitted claims" topic to learn how a previously
transmitted EMC file can be reactivated for re-transmission.
Refer to the "Viewing and maintaining transmission acknowledgment files" topic for
information on how to archive, view, print, and maintain ANSI-997/999 transmission
acknowledgment files.
Refer to the "Data Communications File Maintenance" topic for information on configuring
data communications parameters and the Data Communications Control File.
Refer to the "Data Communication Preferences" topic for information on configuring the
Data Communication Options form "launch" buttons.
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Viewing and maintaining transmission acknowledgment files
Contractors or clearinghouses receiving ANSI-837 format EMC files will acknowledge receipt
by sending an ANSI-997/999 transmission acknowledgment file back to the submitter. PC-ACE
Pro32 provides a facility by which users can archive these ANSI-997/999 transmission
acknowledgment files for subsequent review and/or printing. This topic describes how to stage
your ANSI-997/999 files so that they are automatically archived by PC-ACE Pro32, as well as
the functions available for viewing, printing, maintaining and using the archived
acknowledgment files.
Note: Support for ANSI-997/999 transmission acknowledgment files may not be
available on all installations. If the "Purge archived ANSI-997 acknowledgment files
after 'NN' days" option is disabled (grayed out) on the PC-ACE Pro32 Miscellaneous
preferences form, then this capability is not available on your installation.
Staging Acknowledgment Files For Automatic Archiving
At program startup, PC-ACE Pro32 automatically scans separate Institutional and Professional
"staging" directories looking for new ANSI-997/999 transmission acknowledgment files to be
archived. If new ANSI-997/999 files are present in the staging directories, they are checked for
proper format and archived automatically. This automatic archiving process is also performed
when the Acknowledgment File Log form is opened or when the user manually refreshes the
Acknowledgment File list (see next section for details).
On most PC-ACE Pro32 installations, the user will be required to manually copy the ANSI997/999 files received from the contractor into the appropriate staging directory. The
Institutional and Professional staging directories are:
Institutional: winpcace\ansi997\ackub92
Professional: winpcace\ansi997\ack1500
For single-user installations, these directories will reside on the local drive letter to which PCACE Pro32 was originally installed. For multi-user "networked" installations, these directories
will reside on the shared network drive letter to which PC-ACE Pro32 was originally installed.
Attention: Care must be taken to copy Institutional acknowledgment files to the
Institutional staging directory, and Professional acknowledgment files to the
Professional staging directory. In addition, if your contractor assigns the same filename
to all ANSI-997/999 files, you will need to make sure that the most recently staged
acknowledgment file has been archived before copying a newer acknowledgment file
into the staging directory.
Tip: Installations that use data communications scripts to retrieve the ANSI-997/999
acknowledgment files may also automatically copy them to the appropriate staging
directory. Your distributor should be able to confirm whether or not automatic ANSI997/999 file staging will be performed on your installation.
Viewing, Printing & Maintaining Acknowledgment Files
Archived ANSI-997/999 transmission acknowledgment files can be viewed and/or printed from
the Acknowledgment File Log form. To view the currently archived ANSI-997/999 files, select
the "Maintain" and "Acknowledgment File Log" menu items on either the Institutional or
Professional Claims Menu form. The following operations are available:
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To view and/or print an archived ANSI-997/999 file, select the desired record and click
the "View Report" button (or double-click the desired record). The report may be printed
from the preview form if desired.
To delete an archived ANSI-997/999 file, select the desired record, click the "Delete"
button, and confirm the deletion.
Note: By default, archived ANSI-997/999 transmission acknowledgment files will be
automatically purged after a certain number of days. Refer to the PC-ACE Pro32
Miscellaneous preferences topic for details on how to change the archive period (or
disable automatic purging altogether, if desired).
To refresh the list of archived ANSI-997/999 files, click the "Refresh" button. The staging
directory will be re-scanned for the presence of new ANSI-997/999 files. If new files are
present in the staging directory, they will be checked for proper format and automatically
archived. The displayed list will then be rebuilt to reflect the current archive contents.
Using the Acknowledgment Reports
A detailed discussion of the ANSI-997/999 transmission acknowledgment file format is beyond
the scope of this document. Interpretation questions should be directed to your contractor's
support department. The key fields present in the archive list display and on the individual
acknowledgment reports are as follows:
Acknowledgment Creation Date/Time – Specifies the date and time that the ANSI997/999 transmission acknowledgment file was created. This date/time permits ANSI997/999 files to be ordered chronologically and provides a general timeframe for locating
the associated ANSI-837 claim transmission file.
Serial No. – Specifies the starting serial number assigned during preparation of the
ANSI-837 claim transmission file. The serial number can be compared against the
"Serial No" column in the Claim Transmission Log to identify the specific EMC file
associated with this acknowledgment file. To view the Claim Transmission Log form,
select the "Maintain" and "Transmission Log" menu items on either the Institutional or
Professional Claims Menu form.
Status – Displays a status code indicating whether or not the ANSI-837 transmission file
was accepted or rejected.
Additional identification information is included in the acknowledgment report to aid in
researching transmission errors. Contact your contractor's support department for assistance
in understanding the ANSI-997/999 report nomenclature.
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Reactivating previously transmitted claims
In some situations, it may become necessary to reactivate one or more previously transmitted
claims for retransmission. PC-ACE Pro32 provides two techniques for reactivating claims:
Individual claims in the "transmitted" (TR) location may be reactivated for inclusion in a
subsequent EMC file.
An entire EMC file may be reactivated for retransmission.
This section will describe the procedures required to perform both types of claim reactivation.
Reactivating Transmitted Claims Individually
If one or more transmitted claims need to be resubmitted in a future EMC file, these claims
must first be reactivated. Only claims in the "transmitted" (TR) location may be reactivated.
Once a payment has been made on a claim, it will move to the "paid" (PD) location, and is no
longer eligible for reactivation. This "reactivation" process simply moves the selected claim(s)
from the "transmitted" (TR) location to the "to be transmitted" (CL) location, and sets the status
to "unprocessed" (UNP). The reactivated claim can then be processed and, if no fatal edit
validation errors are present, becomes eligible for inclusion into the next EMC file prepared.
Claim reactivation is performed from the Institutional or Professional Claim List form:
1) Filter the claim list to include only "transmitted only" (TR) claims.
2) If a single claim is to be reactivated, simply select the claim record in the list and choose the
"Reactivate Selected Claim" item from the form's main "Actions" menu. Confirm the
reactivation when prompted. The claim should disappear from the list, since it is no longer
in the "transmitted" (TR) location. You should now find the unprocessed (Status = "UNP")
claim in the "to be transmitted" (CL) location.
3) To reactivate several claims at one time, simply "check" the desired claims. A claim in the
list is "checked" by clicking the left mouse button once while the mouse pointer is positioned
over the list row's left-most column. A checkmark will be visible in the left-most column for
all currently "checked" claims in the list. Choose the "Reactivate All Checked Claims" item
from the form's main "Actions" menu. Confirm the reactivation of all "checked" claims when
prompted.
Tip: To automatically "check" all claims included in a previous transmission file,
select the "Check All Claims From Selected Transmission" item from the form's
main "Filter" menu. The Institutional or Professional Claim Transmission Log form
will display a list of recent transmission files (with the most recent automatically
selected). Select the desired transmission file entry and click the "Select" button.
Upon return to the Claim List form, the program will automatically check all claims
included in the selected transmission. You may then simply choose the "Reactivate
All Checked Claims" item from the form's main "Actions" menu to reactivate these
"checked" claims. Refer to the "Claim List Form Features" topic for more information.
Refer to the "Claim List Form Features" topic for more information on using the Institutional
and Professional Claim List forms.
Reactivating an Entire EMC File for Retransmission
PC-ACE Pro32 archives all prepared EMC files for a duration determined by a Miscellaneous
Preferences setting. Until an EMC file is purged from the archive, it is available for reactivation
and subsequent retransmission. Retransmission of an EMC file might be required, for
example, if the receiver has determined that a previously sent file was somehow corrupted
during transmission.
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Reactivation of an EMC file consists of restoring the selected file from the archive to its original
prepared filename in the server's "winpcace" directory. After reactivation, the EMC file and
other associated system settings exist just as they did when the file was originally prepared for
transmission.
EMC file reactivation is performed from the "Claim Transmission Log" form.
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to display the appropriate Claims Menu form.
2) Select the "Transmission Log" item from the Claims Menu form's main "Maintain" menu.
This action will display the Claim Transmission Log form, which lists details for all archived
EMC files in chronological order. You may resize the form to see any additional list columns
if desired.
3) Select the row describing the EMC file to be reactivated. Click the "View Details" and/or
"View Errors" buttons to preview the original prepare reports, if desired.
4) Click the "Reactivate" button and confirm the reactivation operation when prompted. You
will be notified when the reactivation operation has successfully completed. The EMC file is
now ready for retransmission. Click the "Close" button to close the form.
Note: Archived EMC files (and associated reports) may be manually deleted from the
EMC file archive by selecting the row describing the file to be deleted, and clicking the
"Delete" button. Confirm the deletion when prompted.
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Preparing claim status request files for transmission
Claim status request file "preparation" in PC-ACE Pro32 refers to the act of generating an
ANSI-276 claim status request file suitable for transmission to your claims processor. This file
will contain all relevant status request details for one or more previously transmitted claim s.
Upon receipt of the ANSI-276 file, the claims processor will generate a corresponding ANSI277 claim status response file containing status information for the requested claims. This
ANSI-277 response file can be processed by PC-ACE Pro32, and the user will be able to view
the status information returned for each claim represented in the original ANSI-276 claim
status request file.
Only claims that have been added to the status request queue will be included in the ANSI-276
claim status request file. See the "Claim List Form Features" topic for details on how to build
the status request queue.
Note: Before preparing claims into a status request file for the first time, you may need
to setup your Submitter reference file. This file contains important data that will be used
to build the ANSI-276 file. Separate submitter details exist for Institutional and
Professional claim types. Since some distributors pre-configure the Submitter reference
file, you should check with them before making any changes. Refer to the "Submitter
File Maintenance" topic for more information on configuring this important reference
file.
To prepare a claim status request file in PC-ACE Pro32, follow these steps:
1) Add one or more transmitted claims to the status request queue using the "Request
Selected Claim Status" or "Request All Checked Claims Status" action in the
Institutional or Professional Claim List form.
2) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
3) From the Claims Menu form, select the "Prepare Claim Status Request File" option from
the form's "Maintain" menu. This will display the Claim Status Request File Prepare form,
which provides the following preparation options:
Claim Filter Parameters – queued claims must meet all specified filter criteria to be
considered for preparation.
LOB - specifies a single line of business (LOB) to be considered. Only queued
claims with this LOB will be eligible for preparation. Select the "<< All >>" item to
include queued claims for any line of business.
Note: The Submitter reference file supports LOB-specific setup information if
desired. Selecting a specific LOB for preparation will trigger the use of the
matching LOB-specific submitter information (if any). Refer to the "Submitter
File Maintenance" topic for more information on this advanced feature.
Payer - specifies a single Payer to be considered. Only queued claims for the
selected payer will be eligible for preparation. Select the "<< All Payers for
LOB(s) >>" item to include queued claims for all payers. Note: This selection is
only enabled when a specific LOB has been selected for preparation.
Note: The Submitter reference file supports Payer-specific setup information
if desired. Selecting a specific LOB and Payer for preparation will trigger the
use of the matching LOB/Payer-specific submitter information (if any). Refer
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to the "Submitter File Maintenance" topic for more information on this
advanced feature.
Prepare Options – options that control the claim status request preparation operation.
Submission Status - specifies whether the claim status request file should be
designated as a "production" or "test" submission. The initial state of this option is
determined by a Submitter reference file setting.
4) Specify the desired filter parameters (if any). When ready, click the "Prepare Status
Request" button and confirm your intention to prepare the claim status request file.
Progress information will be displayed as the prepare operation proceeds. You will be
notified when the claim status file prepare operation completes.
5) If desired, click the "View Results" and/or "View Errors" buttons to view reports of the
successfully prepared claim status requests and any failed requests, respectively. These
reports can be printed from the report previewer if desired.
Note: Claims will rarely be rejected during the claim status request prepare
operation. A claim will be rejected, for example, if the "submission" payer specified
on the claim is no longer present in the Payer reference file. Since the claim has
already been transmitted and cannot be modified, you will not be able to request
claim status for these rejected claims.
6) When you have completed your review of the claim status request preparation reports, click
the "Close" button on the Claim Status Request File Prepare form.
7) The prepared ANSI-276 claim status request file is located in the server's "winpcace"
directory. The file is named "bcreq276.dat" for Institutional claims and "bsreq276.dat" for
Professional claims. You may now proceed to transmit the ANSI-276 claim status request
file to your claims processor using their prescribed file transmission procedure.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Claim List Form Features" topic for more information on adding claims to the
status request queues (Institutional and Professional).
Refer to the "Viewing and maintaining claim status response and acknowledgment files"
topic for information on viewing and maintaining the ANSI-277 claim status response and
claim acknowledgment files that will be returned by your claims processor.
Refer to the "Viewing and maintaining the claim status request/response history" topic for
information on viewing and maintaining status request/response history for transmitted
claims.
Refer to the "Submitter File Maintenance" topic for details on configuring the Submitter
reference file.
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Viewing and maintaining claim status response and
acknowledgment files
Contractors or clearinghouses receiving ANSI-276 format claim status request files generated
by PC-ACE Pro32 will retrieve the requested status information from their adjudication system
and respond by sending an ANSI-277 claim status response file back to the submitter.
Contractors or clearinghouses will also send ANSI-277CA claim acknowledgment files in
response to receipt of ANSI-837 claim transmission files. PC-ACE Pro32 provides a facility by
which users can archive these ANSI-277 claim status response files and ANSI-277CA claim
acknowledgment files for subsequent review and/or printing. In addition to simply viewing the
response file, PC-ACE Pro32 will automatically process this file and post the claim status
responses directly to the appropriate Institutional or Professional claims. This topic describes
how to stage your ANSI-277 and ANSI-277CA files so that they are automatically archived and
posted as appropriate by PC-ACE Pro32, as well as the functions available for viewing,
printing, maintaining and using the archived claim status response files and post reports.
Note: Support for ANSI-276/277 claim status request/response files may not be
available on all installations. If the "Purge archived ANSI-277 claim status response
or ack files after 'NN' days" option is disabled (grayed out) on the PC-ACE Pro32
Miscellaneous preferences form, then this capability is not available on your
installation.
Staging Claim Status Response Files and Claim Acknowledgment Files
For Automatic Archiving
At program startup, PC-ACE Pro32 automatically scans separate Institutional and Professional
"staging" directories looking for new ANSI-277 claim status response and ANSI-277CA claim
acknowledgment files to be archived. If any ANSI-277 or ANSI-277CA files are present in the
staging directories, they are checked for proper format and archived automatically. In addition,
the individual responses in ANSI-277 files are automatically posted to the appropriate claims.
This automatic archive/post process is also performed when the Claim Status Response &
Acknowledgment Log form is opened or when the user manually refreshes the Claim Status
Response & Acknowledgment Log list (see next section for details).
On most PC-ACE Pro32 installations, the user will be required to manually copy the ANSI-277
and ANSI-277CA files received from the contractor into the appropriate staging directory. The
Institutional and Professional staging directories are:
Institutional: winpcace\ansi277\statub92
Professional: winpcace\ansi277\stat1500
For single-user installations, these directories will reside on the local drive letter to which PCACE Pro32 was originally installed. For multi-user "networked" installations, these directories
will reside on the shared network drive letter to which PC-ACE Pro32 was originally installed.
Attention: Care must be taken to copy Institutional claim status response and claim
acknowledgment files to the Institutional staging directory, and Professional claim
status response and claim acknowledgment files to the Professional staging directory.
In addition, if your contractor assigns the same filename to all ANSI-277 and/or ANSI277CA files, you will need to make sure that the most recently staged claim status
response or claim acknowledgment file has been archived before copying a newer
response or claim acknowledgment file into the staging directory.
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Tip: Installations that use data communications scripts to retrieve the ANSI-277 claim
status response files and ANSI-277CA claim acknowledgment files may also
automatically copy them to the appropriate staging directory. Your distributor should
be able to confirm whether or not automatic ANSI-277 file staging will be performed on
your installation.
Viewing, Printing & Maintaining Claim Status Response Files, Claim
Acknowledgment Files and Post Reports
Archived ANSI-277 claim status response files, ANSI-277CA claim acknowledgment files, and
claim status response post reports can be viewed and/or printed from the Claim Status
Response & Acknowledgment Log form. To view the currently archived ANSI-277 and ANSI277CA files, select the "Maintain" and "Claim Status Response & Acknowledgment Log"
menu items on either the Institutional or Professional Claims Menu form. The following
operations are available:
To view and/or print an archived ANSI-277 response file or ANSI-277CA claim
acknowledgment file report, select the desired record and click the "View Response
Report" or "View Ack Report" button, respectively (or double-click the desired record).
The report may be printed from the preview form if desired.
To view and/or print the post report for an archived ANSI-277 response file, select the
desired record and click the "View Post Report" button. The report may be printed from
the preview form if desired.
To delete an archived ANSI-277 or ANSI-277CA file and its associated post report,
select the desired record, click the "Delete" button, and confirm the deletion.
Note: By default, archived ANSI-277 claim status response and ANSI-277CA claim
acknowledgment files will be automatically purged after a certain number of days.
Refer to the PC-ACE Pro32 Miscellaneous preferences topic for details on how to
change the archive period (or disable automatic purging altogether, if desired).
Individual claim status responses which have been posted to claims will remain on
file even after the original archived response file has been manually deleted or
automatically purged.
To refresh the list of archived ANSI-277 and ANSI-277CA files, click the "Refresh"
button. The staging directory will be re-scanned for the presence of new ANSI-277 or
ANSI-277CA files. If new files are present in the staging directory, they will be checked
for proper format, and automatically archived and posted, if appropriate. The displayed
list will then be rebuilt to reflect the current archive contents.
Tip: Right-click the mouse on the desired ANSI-277 or ANSI-277CA archive record
to access all available actions. For ANSI-277 files, this popup menu provides
several additional actions which allow the user to print post reports containing only
the successfully posted responses or only responses that could not be posted.
Using the Claim Status Response Reports
The ANSI-277 claim status response file is presented by PC-ACE Pro32 in a human-readable
report format. The report presents general identification information along with the claim-level
status response codes and payment details returned by the contractor for each claim. Since
the individual responses are posted directly to the applicable claims, this report is typically
used as a secondary reference source. There may be situations in which ambiguous status
responses returned by the contractor will not be posted to the original claim. In these
situations, you will be referred back to the original claim status response file (and this report)
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for additional information. Contact your contractor's support department for assistance in
understanding the ANSI-277 report nomenclature and claim status code interpretation.
Using the Claim Status Response Post Reports
The ANSI-277 claim status response post report presents the claim-by-claim results of the
automatic response posting operation. A response posting will fail for either of the following
reasons:
The claim for which status was requested no longer exists. The claim has been purged,
archived, or reactivated from the "TR – transmitted only" or "PD – paid only" location.
Multiple claim status responses have been returned by the contractor for the same
unique claim trace number. This typically indicates that the contractor could not uniquely
identify the claim of interest based on the identifying information included in the ANSI276 claim status request file. Multiple responses may be returned at the discretion of the
contractor. PC-ACE Pro32 will not post any of the ambiguous responses directly to the
claim, but will instead post an "attention" notification which directs the user back to the
original archived claim status response file/report. The user must review this report
manually to determine which one of the multiple responses is applicable (if any).
The ANSI-277 claim status response post report will display an explanatory error message for
each response that could not be posted.
Using the Claim Acknowledgment Reports
The ANSI-277CA claim acknowledgment file is presented by PC-ACE Pro32 in a humanreadable report format. The report presents general identification information along with the
acceptance or rejection status codes returned by the contractor for each claim. Contact your
contractor's support department for assistance in understanding the ANSI-277CA report
nomenclature and accept/reject status code interpretation.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Claim List Form Features" topic for more information on adding claims to the
status request queues (Institutional and Professional).
Refer to the "Preparing claim status request files for transmission" topic for information on
creating ANSI-276 claim status request files to send to your claims processor.
Refer to the "Viewing and maintaining the claim status request/response history" topic for
information on viewing and maintaining status request/response history for transmitted
claims.
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Viewing and maintaining the claim status request/response
history
PC-ACE Pro32 keeps a history of claim status requests and responses for each transmitted
claim. Requests are added to this history log as the final step of the ANSI-276 claim status
request prepare operation. Responses are recorded in the history log during automatic posting
of the ANSI-277 claim status response files returned from the contractor or clearinghouse. PCACE Pro32 provides a facility by which users can view, print and maintain this claim
request/response history. This topic describes how to access and use this advanced capability.
Refer to the "Related Topics" links at the end of this topic for more information on how to
request claim status and process the returned status response files.
Note: Support for ANSI-276/277 claim status request/response files may not be
available on all installations. If the "Purge archived ANSI-277 claim status response
or ack files after 'NN' days" option is disabled (grayed out) on the PC-ACE Pro32
Miscellaneous preferences form, then this capability is not available on your
installation.
Determining Status Request/Response Availability
The Institutional and Professional Claim List forms include the following columns for use in
determining the availability of status request/response history for transmitted claims.
SR (Status Response Indicator) – This indicator will display an "R" on claims where status
has been requested, but where a response has not yet been received. An "A" value
indicates that status response information is available for this claim. An empty SR column
indicates that no claim status request/response history is available for the claim.
Status Date (Status Response Date) – Specifies the date of the most recent status
request or posted status response for the claim. This date column will be empty if no claim
status request/response history is available for the claim.
Note: These columns should be visible by default at the far right of the Institutional and
Professional Claim List forms whenever the "TR", "PD" or "TR/PD" claim location is
selected. You may need to maximize the window or scroll the list horizontally to bring
these columns into view. If these columns are not present, you will need to add the
associated fields to the current claim list column configuration in the "Claim List
Preferences" form. Select the "Preferences" item from the PC-ACE Pro32 main
toolbar's "File" menu to display the Preferences form. Select the "Claim List" tab,
choose either the "Institutional Claim List" or "Professional Claim List" radio button
(if available), and then select the "Transmitted (TR)" nested tab. Move the "Status
Response Ind" and "Status Response Date" fields from the available fields list to the
selected fields list. Reorder the new fields in the selected fields list as desired. Select
the "Paid/History (PD)" tab and repeat this configuration process. Save the preference
setting changes. This configuration process must be performed separately for the
Institutional Claim List form and the Professional Claim List form.
Viewing, Printing & Maintaining Claim Status Request/Response History
The status request/response history for any transmitted claim can be viewed and/or printed
from the Claim Status Request/Response History form. Access to this history log is available
from the Institutional and Professional Claim List forms. On either claim list, select the "TR/PD
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– transmitted+paid" location to display all transmitted claims. To access the history log, select
the claim record of interest in the list and choose the "Show Selected Claim Status History"
item from the form's main "Actions" menu. The Claim Status Request/Response History form
will display all available status requests and responses for this claim.
The Claim Status Request/Response History form displays a summary of each request or
response, including the associated date/time, the "Action" (or type), and a few key status
response data elements. The possible "Action" types include:
Request – Records the date/time a claim status history request was made on behalf of
this claim. This is actually the date/time associated with the ANSI-276 claim status request
file prepared by PC-ACE Pro32.
Response – Identifies a posted response for this claim. A summary of the status response
is displayed in the list's columns. Additional details for this response are available for
viewing if desired (see below for instructions). This includes general claim identification
information along with the claim-level status response codes and payment details returned
by the contractor. Reference information is also available to locate the original claim status
response file should it be needed.
Attention – Indicates that a response was available for this claim, however, could not be
posted for some specific reason. Additional information directs the user to the original
claim status response report. The most common cause for this "attention" condition is an
ambiguous claim status response. This occurs when the response file contains more than
one response referencing the same unique claim trace number.
The following operations are available on the Claim Status Request/Response History form:
To view status response details or "attention" information, select the desired record and
click the "View" button (or double-click the desired record).
To delete a request/response entry, select the desired record, click the "Delete" button,
and confirm the deletion.
To view and/or print the complete status request/response history for this claim, click the
"Print History" button. The report may be printed from the preview form if desired.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Claim List Form Features" topic for more information on adding claims to the
status request queues (Institutional and Professional).
Refer to the "Preparing claim status request files for transmission" topic for information on
creating ANSI-276 claim status request files to send to your claims processor.
Refer to the "Viewing and maintaining claim status response and acknowledgment files"
topic for information on viewing and maintaining the ANSI-277 claim status response files
that will be returned by your claims processor.
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Printing claims
Claims can be printed in PC-ACE Pro32 using either the traditional "pre-printed forms" method
or an advanced "image overlay" technique. These 2 approaches are described below, along
with suggestions on when each method might be appropriate.
Pre-Printed Forms Method - This traditional method prints just the actual claim field
values at positions on the page that should line up with pre-printed CMS-1450
(Institutional) or Professional claim forms. Use this printing method when you require
claims to be printed on the actual red pre-printed claim forms. Most optical character
recognition (OCR) equipment used to scan paper claims requires that these red forms be
used. This method also provides the quickest means to get a claim printout for hardcopy
review.
Image-Overlay Method - This advanced method automatically overlays the claim field
values onto a graphical image of the blank claim form, resulting in a complete claim image
that can be printed on stock paper. The image-overlay technique eliminates all the paper
alignment headaches often associated with printing onto pre-printed claim forms. Use this
printing method to print claims for archiving or distribution.
Note: The image-overlay printing method requires that the free Adobe Acrobat
Reader (Version 4.0 or later) be installed on your system. This reader is available
for download from Adobe (www.adobe.com). When the Acrobat Reader is properly
installed, PC-ACE Pro32 will automatically detect and configure the path to the
ACRORD32.EXE program.
The steps involved in printing a claim (or selection of claims) are the same regardless of the
selected printing method:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the appropriate Claims Menu form.
2) Click the "List Claims" button on the Claims Menu form to display the appropriate Claim
List form. All claim printing is performed from the claim list.
3) To print a single claim, simply select the desired claim from the list and select the "Print
Selected Claim" item from the Claim List form's main "Actions" menu (or convenient rightclick popup menu). The Claim Print Options form will be displayed.
Tip: To print a selection of claims, simply "check" the desired claims and select the
"Print All Checked Claims" item from the Claim List form's main "Actions" menu.
Refer to the "Claim List Form Features" topic for more information on multiple-claim
selection.
4) The Claim Print Options form allows the user to override default preferences for things like
destination printer, printing method (pre-printed forms versus image-overlay), claim form
version, and miscellaneous options. Click the "Preview" button to preview the claim(s)
before printing (available with image-overlay method only). Click the "Print" button to print
the claim(s) without previewing them.
Claim "previewing" for claims printed using the image-overlay method employs the Adobe
Acrobat Reader. Use the Acrobat Reader's "print" option to print a previewed claim. When
you have previewed and optionally printed the claim, close the Acrobat Reader program.
This will signal PC-ACE Pro32 that you are ready to continue.
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Attention: You will not be able to resume activities in PC-ACE Pro32 until the
Acrobat Reader program has been exited. Simply closing the claim document within
the reader is not enough to signal PC-ACE Pro32 to continue.
5) If you have selected multiple claims, they will be printed in sequence based on the current
Claim List form’s "Sort By:" selection. A progress form will display details about the claim
currently being printed. Click the "Cancel" button on this progress form to cancel the
printing session following the claim currently being printed.
A Few Technical Notes
Here is some additional technical information that you need to know about printing claims in
PC-ACE Pro32:
The image-overlay printing method option will be enabled only if the Adobe Acrobat
Reader (Version 4.0 or later) is properly installed on the system. You must exit PC-ACE
Pro32 before installing the Acrobat Reader. A properly installed reader will be detected
automatically the next time PC-ACE Pro32 is started. If necessary, you can manually
configure the Acrobat Reader executable file (ACRORD32.EXE) path from the "Misc" tab
of the PC-ACE Pro32 Preferences form.
Tip: The Adobe Acrobat Reader has its own preference settings that will let you
choose the initial document magnification level and get rid of the splash screen that is
shown by default every time the reader is started.
Claim printing default values for destination printer, printing method (pre-printed forms
versus image-overlay), pre-printed position and point size adjustments, claim form version,
and numerous miscellaneous options can be set from the "Printing" tab of the PC-ACE
Pro32 Preferences form. Claim printing defaults are set independently for Institutional and
Professional claim printing (if you are licensed for both claim types). These default settings
will be used during claim print operations unless overridden at print time from the Claim
Print Options form.
Using the "Payer Options" selections, claims may be printed on behalf of the their
alternate payers if desired. An "alternate" payer is any payer specified on the claim other
than the submission payer. For example, if a Medicare payer is specified as primary on a
Medicare claim, then the primary payer will be designated as the "submission" payer. In
this scenario, the secondary and tertiary payers are considered "alternate" payers.
Alternate Payers 1 and 2 are defined based on the claim's submission payer as follows:
Submission:
Alt. Payer 1:
Alt. Payer 2:
Primary
Secondary
Tertiary
Secondary
Primary
Tertiary
Tertiary
Primary
Secondary
When a claim is printed for an alternate payer, PC-ACE Pro32 will attempt to populate the
printed fields "as though" the selected alternate payer was the submission payer. In
general, this means that the payer-specific and provider-specific information included on
the printed claim will reflect the alternate Payer ID and LOB (line of business). For
alternate payer printing to work most effectively, all payers specified on the claim must be
on-file in the PC-ACE Pro32 Payer reference file. In addition, provider records for the
alternate claim payer LOBs must also be on-file in the PC-ACE Pro32 Institutional (or
Professional) Provider reference file, and must be associated with the submission provider
record.
Tip: This capability makes it easy to print secondary/tertiary claims without requiring
the creation of a separate claim for the alternate payer.
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Tip: If a request is made to print an alternate payer that does not exist on the claim
being printed, the request will simply be ignored. This behavior makes it possible to
request alternate payer printing for multiple "checked" claims without regard for
whether or not the alternate payers are actually present on all the claims.
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Claim attachments can be optionally printed (when present) by checking the "Print claim
attachments if present" option on the Claim Print Options form. Claim attachments
should always be printed on stock paper. If you are printing your claims using the preprinted forms method onto actual CMS-1450/1500 red forms, then you will want to print all
attachments at the end of the print run. Doing this will give you the opportunity to change
the printer paper prior to printing the attachments. Make sure the "Print all claim
attachments at the end of multiple-claim print run when appropriate" option on the
"Printing" tab of the PC-ACE Pro32 Preferences form is checked.
Common Reference File Procedures
Posting claim payments (Institutional)
PC-ACE Pro32 maintains an optional Institutional claim payments database for organizations
that wish to track payment data in the system. Any number of "payments" may be posted
against a transmitted Institutional claim. The payment history for a claim can be accessed from
either the Institutional Claim List form or the Institutional Claim Form as follows:
1) Click the "Institutional Claims Processing" button from the PC-ACE Pro32 Main Toolbar
to display the Institutional Claims Menu form.
2) Click the "List Claims" button on the Institutional Claims Menu form to display the
Institutional Claim List form. By default, the list will display claims in the "to be transmitted"
(CL) location.
3) On the Institutional Claim List form, select either the "transmitted only" (TR), "paid only"
(PD), or "transmitted + paid" (TR/PD) claims location to display claims eligible for payment.
Note: Claims are assigned to the "transmitted" (TR) location as soon as they are
prepared into an EMC file for transmission. When the first payment is posted to a
"transmitted" claim, the claim is moved to the "paid" (PD) location, where it will
remain indefinitely. Payments may be posted to claims in either the "transmitted"
(TR) or "paid" (PD) locations, but not to claims in the "to be transmitted" (CL)
location.
Tip: If you plan on posting payments to more than one claim, we recommend that you
select the combined "transmitted + paid" (TR/PD) claims location. Updates to the
claim list are more efficient to process from this location, since claims being moved
from the "transmitted" (TR) to "paid" (PD) status will not force a requery of the list's
contents.
4) Select the desired claim from the list and perform either of the following to access the
claim's payment history.
Select the "Show Selected Claim Payments" item from the Institutional Claim List
form's main "Actions" menu (or from the convenient right-click popup menu).
Click the "View" button (or double-click the selected record) to display the claim in
the Institutional Claim Form. Click the "Show Payment History" button to access
the payment history for this claim.
5) The Claim Payment History form lists all existing payments made to the selected claim (if
any). Perform the desired payment-related tasks from this list, including:
To post a new payment, click the "New" button and enter the payment date and
amount on the Claim Payment Details form. The "Date Paid" field is defaulted to the
current system date and can be changed if desired. Complete some or all of the
optional payment record fields if desired. When all desired payment fields have been
entered, click the "OK" button to save the payment record.
To modify an existing payment record, select the desired record, click the
"View/Update" button (or double-click the selected record) and modify the payment
field values as required. Click the "OK" button to save the modified payment record.
To delete a payment record, select the desired record, click the "Delete" button, and
confirm the deletion.
6) The Claim Payment History form maintains running totals of all claim payments posted to
the selected claim. When you have completed the payment posting activities for this claim,
click the "Close" button to return to the previous form. The Institutional Claim List form will
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reflect the most recent payment date and total amount paid in the "Paid Date" and "Paid
Amount" columns, respectively.
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Posting claim payments (Professional)
PC-ACE Pro32 maintains an optional Professional claim payments database for organizations
that wish to track payment data in the system. Any number of "payments" may be posted
against a transmitted Professional claim. The payment history for a claim can be accessed
from either the Professional Claim List form or the "The Professional Claim Form" as follows:
1) Click the "Professional Claims Processing" button from the PC-ACE Pro32 Main Toolbar
to display the Professional Claims Menu form.
2) Click the "List Claims" button on the Professional Claims Menu form to display the
Professional Claim List form. By default, the list will display claims in the "to be transmitted"
(CL) location.
3) On the Professional Claim List form, select either the "transmitted only" (TR), "paid only"
(PD), or "transmitted + paid" (TR/PD) claims location to display claims eligible for payment.
Note: Claims are assigned to the "transmitted" (TR) location as soon as they are
prepared into an EMC file for transmission. When the first payment is posted to a
"transmitted" claim, the claim is moved to the "paid" (PD) location, where it will
remain indefinitely. Payments may be posted to claims in either the "transmitted"
(TR) or "paid" (PD) locations, but not to claims in the "to be transmitted" (CL)
location.
Tip: If you plan on posting payments to more than one claim, we recommend that you
select the combined "transmitted + paid" (TR/PD) claims location. Updates to the
claim list are more efficient to process from this location, since claims being moved
from the "transmitted" (TR) to "paid" (PD) status will not force a requery of the list's
contents.
4) Select the desired claim from the list and perform either of the following to access the
claim's payment history.
Select the "Show Selected Claim Payments" item from the Professional Claim List
form's main "Actions" menu (or from the convenient right-click popup menu).
Click the "View" button (or double-click the selected record) to display the claim in
the Professional Claim Form. Click the "Show Payment History" button to access
the payment history for this claim.
5) The Claim Payment History form lists all existing payments made to the selected claim (if
any). Perform the desired payment-related tasks from this list, including:
To post a new payment, click the "New" button and enter the payment date on the
Claim Payment Details form. The "Date Paid" field is defaulted to the current system
date and can be changed if desired. Payment data for Professional claims must be
entered on a "per-line-item" basis. Click the "Amount Paid" cell for the line item to
be paid (click twice for "edit" mode), enter the payment amount, and press the
"ENTER" or "TAB" key to accept the entry. Complete some or all of the optional
payment record fields and line item cells if desired. The claim-level "Amount Paid"
field at the top of the form will display a running total of the "Amount Paid" values
entered for all claim lines. When all desired payment fields have been entered, click
the "OK" button to save the payment record.
To modify an existing payment record, select the desired record, click the
"View/Update" button (or double-click the selected record) and modify the payment
field values as required. Click the "OK" button to save the modified payment record.
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Note: The "Date Paid" value for an existing claim payment record cannot be
modified. To change the payment date, you must delete the existing payment
record and add a new one with the correct date.
To delete a payment record, select the desired record, click the "Delete" button, and
confirm the deletion.
6) The Claim Payment History form maintains running totals of all claim payments posted to
the selected claim. When you have completed the payment posting activities for this claim,
click the "Close" button to return to the previous form. The Professional Claim List form will
reflect the most recent payment date and total amount paid in the "Paid Date" and "Paid
Amount" columns, respectively.
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Archiving and unarchiving claims
Transmitted claims in PC-ACE Pro32 can be optionally moved "off-line" to any number of
user-defined claim archives. Claim archiving provides the following advantages:
Archiving claims reduces the size and optimizes the performance of the current claims
database.
Archiving claims eliminates claims that are no longer of interest from the current claims
database, making it easier to locate and work with the current claims.
Archiving promotes organized storage of older claims without requiring that they be
purged. Claim archives can be maintained by transmit date, line-of business, "submission"
payer, or other preferred criteria.
Claim archive databases look and act much like the current database. With a few minor
exceptions, the same actions that can be taken on transmitted claims in the current database
can also be taken on archived claims. For example, archived claims can be viewed and printed
just like claims in the current database. The payment history of archived claims can be viewed
as well.
Tip: To greatly reduce the time required to perform claim archiving activities on
networked installations, it is strongly recommended that such activities be initiated
from the server's console. It is also recommended, though not required, that no other
users be accessing PC-ACE Pro32 during claim archiving activities.
Note: Access to various features of the PC-ACE Pro32 claim archiving system is
controlled by user permissions. For example, a user may be able to archive and
unarchive claims, but not have permission to create new claim archives. If any (or all)
of the claim archiving features described in this topic are unavailable, then you either
do not have the required archive permissions, or your distributor does not support the
claim archiving function.
All claim archive functions are performed from the familiar Institutional or Professional Claim
List form. To archive and unarchive claims, follow these general steps:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
button or "Professional Claims Processing" button to display the corresponding Claims
Menu form.
2) Click the "List Claims" button on the Claims Menu form to display the Institutional or
Professional Claim List form. By default, the list will display claims in the "to be transmitted"
(CL) location.
3) From the Claim List form's main "File" menu, select the "Open Claim Archive" item to
display the Open Claim Archive form. This form will display a list of all existing claim
archives (if any).
4) To open an existing claim archive, select the desired archive from the list and click the
"Open" button (or just double-click the list entry). The claim archive will be opened and you
will be returned to the Claim List form. Skip over the next step.
5) To create a new archive (if you have archive maintenance permission), click the "New"
button and enter a descriptive name for the new archive. The empty archive will be created
and the corresponding entry will be added to the selection list. Select the new archive from
the list and click the "Open" button (or just double-click the new list entry). The new claim
archive will be opened and you will be returned to the Claim List form.
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Tip: Claim archive names must adhere to your server's directory naming convention. If
Windows long file/directory names are permitted, then you can give the archive a
descriptive name. Otherwise, you may be limited to 8 characters. Archive names can
contain only alphabetic characters, numeric characters, underscore ("_") characters,
and spaces. You will receive an error message if the chosen archive name is
unacceptable.
6) Once you're back to the Claim List form, select the "View Archived Claims" item from the
form's main "File" menu to view the claims in the open claim archive. Select the "View
Current Claims" item from the main "File" menu to toggle back to the current claims.
7) Only transmitted and paid claims can be archived, so choose either the "transmitted only"
(TR), "paid only" (PD), or "transmitted + paid" (TR/PD) item from the "Location" dropdown list.
8) To archive a single claim, select the desired claim from the list and choose the "Archive
Selected Claim" item from the Claim List form's main "Actions" menu (or the convenient
right-click popup menu). The selected claim will disappear from the current claims list. To
archive multiple claims at once, simply "check" the desired claims and select the "Archive
All Checked Claims" item from main "Actions" menu. All "checked" claims will disappear
from the current claims list. Refer to the "Claim List Form Features" topic for more
information on using this form's powerful multi-selection feature.
9) Select the "View Archived Claims" item from the Claim List form's main "File" menu to
once again view the claims in the open claim archive. You should see the claims you just
archived.
10) If you desire, you can unarchive the same claims by selecting (single) or "checking"
(multiple) the desired claim(s) and choosing either the "Unarchive Selected Claim" or
"Unarchive All Checked Claims" item from the Claim List form's main "Actions" menu.
11) When you are finished reviewing (and possibly unarchiving) claims in the claim archive,
select the "View Current Claims" item from the main "File" menu to toggle back to the
current claims.
12) Select the "Close Claim Archive" item from the main "File" menu to close the open claim
archive. You will be prompted to "pack" the claim archive before closing. Click the "Yes"
button to pack and close the archive, the "No" button to close the archive without packing,
or the "Cancel" button to leave the archive open.
Attention: Packing a claim archive database minimizes the disk space requirements
and enhances performance. It is recommended that claim archive databases be
packed periodically, especially after groups of claims have been unarchived or
purged from the archive. The packing process can be lengthy for large
databases. Once the packing operation has started, it must continue to
completion. We recommend packing claim archives only when no other users
are accessing PC-ACE Pro32.
Tip: If you close the Claim List form without first closing an open claim archive, the
archive is closed automatically, and you will receive the "pack" prompt (described
above).
Note: If claims have been archived, you will receive a notification when the archive is
closed concerning "packing" the current claims database. The system administrator
should pack the current claims database periodically to keep the database size
minimized and to maintain optimum system performance. Refer to the "Packing and
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reindexing the databases" topic for information on packing the Institutional and/or
Professional current claims database.
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Adding a new eligibility benefit request
New patient eligibility benefit requests can be added to PC-ACE Pro32 from the Eligibility
Benefit Request List form. The operation of this list form is identical for Institutional and
Professional request types. Perform the following steps to access the Eligibility Benefit
Request List form and open a new eligibility benefit request:
1) Click either the "Institutional Claims Processing" or "Professional Claims Processing"
button on the PC-ACE Pro32 Main Toolbar to display the respective Claims Menu form.
2) From the Institutional or Professional Claims Menu form, select the "Maintain" and
"Maintain Eligibility Benefit Requests" menu items to open the respective Eligibility
Benefit Request List form.
3) Click the "New" button on the request list form to open either the complete Eligibility Benefit
Request Form or the simplified Service Type Eligibility Benefit Request Form (depending on
preference settings) and begin entering information on the new eligibility benefit request.
You may also open either request form from the Eligibility Benefit List Form's main
"Actions" menu.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Maintain Eligibility Benefit Requests" item is not visible on the
"Maintain" menu, then this capability is not available on your installation. In addition, the
simplified Service Type Eligibility Benefit Request Form may not be available on all
installations.
Requests are manually entered on the respective Eligibility Benefit Request Form or simplified
Service Type Eligibility Benefit Request Form. Refer to the associated Help topic for
information on entering eligibility benefit requests. The data fields on the complete Eligibility
Benefit Request Form are typically entered in the order presented - from left-to-right and topto-bottom - on each tab of the request form. The fields that are most commonly used are
concentrated on the leftmost tabs. Lookups available on key fields (e.g., Patient PCN) can
significantly speed the process of entering eligibility benefit requests. The data fields on the
simplified Service Type Eligibility Benefit Request Form should be completed in top-to-bottom
order. Edit validation errors may be encountered during this entry process if the data entered
violates any of the predefined edits for the specific request type. Correct any such edit errors
and click the "Save" button to save the request. Requests containing unresolved edit errors
may be saved if desired by clicking either the "Save With Errors" button (visible if only nonfatal errors exist) or "Save With Fatal" button (visible if any fatal errors exist). Only one of
these buttons will be visible at any given time.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Institutional & Professional Claims Menus" topic for more information about
the Claims Menu form.
Refer to the "Eligibility Benefit Request List Form Features" topic for details on using the
Eligibility Benefit Request List form.
Refer to the "Eligibility Benefit Request Form" topic for more information on using the
eligibility benefit request form.
Refer to the "Service Type Eligibility Benefit Request Form" topic for more information on
using the simplified Service Type eligibility benefit request form (if available on your
installation).
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Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
Refer to the on-line help "Common Claim Activities" folder for hyperlinks to other
eligibility benefit request topics of interest.
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Listing, modifying and maintaining eligibility benefit requests
Patient eligibility benefit requests in PC-ACE Pro32 are listed, modified, and otherwise
maintained from the Eligibility Benefit Request List Form. The operation of this list form is
identical for Institutional and Professional request types. To access the Eligibility Benefit
Request List form:
1) Click either the "Institutional Claims Processing" or "Professional Claims Processing"
button on the PC-ACE Pro32 Main Toolbar to display the respective Claims Menu form.
2) From the Institutional or Professional Claims Menu form, select the "Maintain" and
"Maintain Eligibility Benefit Requests" menu items to open the respective Eligibility
Benefit Request List form.
Most actions to be performed on an eligibility benefit request may be executed from the
Eligibility Benefit Request List form. Requests can be created, viewed/modified, copied,
deleted, reactivated, and held/released from the list. In addition, archived eligibility benefit
responses for individual requests can be viewed and printed from the request list form. Refer
to the "Eligibility Benefit Request List Form Features" topic for complete details on the features
and operation of the powerful Eligibility Benefit Request List form.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Maintain Eligibility Benefit Requests" item is not visible on the
"Maintain" menu, then this capability is not available on your installation.
Viewing & Modifying Eligibility Benefit Requests
Viewing and/or modifying existing eligibility benefit requests from the Eligibility Benefit Request
List form can be performed with these general steps:
1) Use the Eligibility Benefit Request List form's powerful sorting and filtering capabilities to
locate the request of interest in the list.
2) Select the desired eligibility benefit request in the list and click the "View/Update" button to
display the request details in the request form. Alternatively, just double-click the desired
request record in the list.
3) Make all desired changes to the request. Refer to the Eligibility Benefit Request Form topic
for details on the many productivity enhancing features available on this powerful request
form.
4) When all changes have been made, click the "Save" button to save the request record and
close the form. Review and correct any edit validation errors as needed. Alternatively, click
the "Cancel" (or "Close") button to cancel any pending request changes.
Actions On Multiple Eligibility Benefit Requests
Many of the eligibility benefit request actions available in the Eligibility Benefit Request List
form are applicable to both single (selected) requests as well as groups of "checked" requests.
This powerful multi-selection capability makes operating on groups of requests a snap! Simply
use the Eligibility Benefit Request List form's advanced filtering options to narrow the eligibility
benefit request list contents down until it contains only the desired requests. Then select the
"Check All Requests" action from the main or popup menu to instantly mark (i.e., "check") all
the requests of interest. A number of actions are available from the main or popup menu to
operate on the entire group of requests in a single session. Refer to the "Eligibility Benefit
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Request List Form Features" topic for complete details on selecting and acting on multiple
eligibility benefit requests at once.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Eligibility Benefit Request List Form Features" topic for details on using the
Eligibility Benefit Request List form.
Refer to the "Eligibility Benefit Request Form" topic for more information on using the
Institutional and Professional eligibility benefit request forms.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
Refer to the on-line help "Common Claim Activities" folder for hyperlinks to other
eligibility benefit request topics of interest.
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Preparing eligibility benefit request files for transmission
Patient eligibility benefit request file "preparation" in PC-ACE Pro32 refers to the act of
generating an ANSI-270 eligibility benefit request file suitable for transmission to your claims
processor. This file will contain all relevant details for one or more eligibility benefit requests.
Upon receipt of the ANSI-270 file, the claims processor will generate a corresponding ANSI271 eligibility benefit response file containing the requested eligibility/benefit information. This
ANSI-271 response file can be processed by PC-ACE Pro32, and the user will be able to view
the eligibility/benefit information returned for each request represented in the original ANSI-270
eligibility benefit request file.
Only eligibility benefit requests in the "to be submitted" (EL) location are eligible for
preparation. When a request is "prepared" into an ANSI-270 eligibility benefit request file, it is
automatically moved to the "submitted" (TR) location. Residence in the "submitted" (TR)
location reflects its transmitted state and also prevents the request from being inadvertently
retransmitted.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Prepare Eligibility Benefit Request File" item is not visible on the
"Maintain" menu when performing the steps described in this topic, then this capability
is not available on your installation.
Note: Before preparing eligibility benefit requests for the first time, you may need to
setup your Submitter reference file. This file contains important data that will be used to
build the ANSI-270 file. Separate submitter details exist for Institutional and
Professional request types. Since some distributors pre-configure the Submitter
reference file, you should check with them before making any changes. Refer to the
"Submitter File Maintenance" topic for more information on configuring this important
reference file.
To prepare eligibility benefit requests in PC-ACE Pro32, follow these simple steps:
1) From the PC-ACE Pro32 Main Toolbar, click either the "Institutional Claims Processing"
or "Professional Claims Processing" button to open the desired Claims Menu form.
2) From the Claims Menu form, select the "Maintain" and "Prepare Eligibility Benefit
Request File" menu items to open the respective Eligibility/Benefit Request Prepare form.
This form provides the following preparation options:
Request Filter Parameters – eligibility benefit requests must meet all specified filter
criteria to be considered for preparation.
LOB - specifies a single line of business (LOB) to be considered. Only requests
with this LOB will be eligible for preparation. Select the "<< All >>" item to include
requests for any line of business.
Note: The Submitter reference file supports LOB-specific setup information if
desired. Selecting a specific LOB for preparation will trigger the use of the
matching LOB-specific submitter information (if any). Refer to the "Submitter
File Maintenance" topic for more information on this advanced feature.
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Payer - specifies a single Payer to be considered. Only requests being submitted
to the selected payer will be eligible for preparation. Select the "<< All Payers for
LOB(s) >>" item to include requests for all payers. Note: This selection is only
enabled when a specific LOB has been selected for preparation.
Common Reference File Procedures
Note: The Submitter reference file supports Payer-specific setup information
if desired. Selecting a specific LOB and Payer for preparation will trigger the
use of the matching LOB/Payer-specific submitter information (if any). Refer
to the "Submitter File Maintenance" topic for more information on this
advanced feature.
Prepare Options - options that control the eligibility benefit request preparation
operation.
Submission Status - specifies whether the ANSI-270 file should be designated as
a "production" or "test" submission. The initial state of this option is determined by
a Submitter reference file setting.
Include Error Requests? - specifies whether eligibility benefit requests with "nonfatal errors" (Status = "ERR") are to be eligible for preparation. When checked, all
requests in the "to be submitted" (EL) location with a status or either "CLN" (clean)
or "ERR" (contains non-fatal errors) will be eligible for preparation. When
unchecked, only clean requests will be eligible for preparation. The initial state of
this option is determined by a Submitter reference file setting.
Attention: The default settings for these control options are typically configured
by your distributor. We recommend overriding these option settings only under
the instruction of your distributor or an authorized technical support specialist.
3) Specify the desired filter parameters (if any) and preparation options. When ready, click the
"Prepare Eligibility Request" button and confirm your intention to prepare all eligible
eligibility benefit requests. Progress information will be displayed as the prepare operation
proceeds. You will be notified when the eligibility benefit request file prepare operation
completes.
4) If desired, click the "View Results" and/or "View Errors" buttons to view reports of the
successfully prepared eligibility benefit requests and rejected requests, respectively. These
reports can be printed from the report preview form if desired. The reports for the most
recent eligibility benefit request prepare operation are also available from the "View" menu
on the Institutional & Professional Claims Menu forms.
Note: Eligibility benefit requests will rarely be rejected during the prepare operation.
A request may be rejected, for example, if the Information Source (i.e., payer)
specified on the request is no longer present in the Payer reference file. Rejected
eligibility benefit requests must be re-processed and corrected before they can be
successfully prepared.
5) When you have completed your review of the eligibility benefit request preparation reports,
click the "Close" button on the Eligibility/Benefit Request Prepare form.
6) The prepared ANSI-270 eligibility benefit request file is located in the server's "winpcace"
directory. The file is named "bcreq270.dat" for Institutional requests and "bsreq270.dat" for
Professional requests. You may now proceed to transmit the ANSI-270 eligibility benefit
request file to your claims processor using their prescribed file transmission procedure.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Adding a new eligibility benefit request" topic for more information on
creating patient eligibility benefit requests.
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Refer to the "Viewing and maintaining eligibility benefit response files" topic for information
on viewing and maintaining the ANSI-271 eligibility benefit response files that will be
returned by your claims processor.
Refer to the "Viewing the eligibility benefit response for a specific request" topic for
information on viewing the eligibility benefit response returned for a specific request.
Refer to the "Submitter File Maintenance" topic for details on configuring the Submitter
reference file.
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Viewing and maintaining eligibility benefit response files
Claims processors receiving ANSI-270 format patient eligibility benefit request files generated
by PC-ACE Pro32 will retrieve the requested eligibility/benefit information from their system
and respond by sending an ANSI-271 eligibility benefit response file back to the submitter. PCACE Pro32 provides a facility by which users can archive these ANSI-271 eligibility benefit
response files for subsequent review and/or printing. In addition to simply viewing the entire
response file, PC-ACE Pro32 will automatically process this file and post the responses
directly to the original Institutional or Professional eligibility benefit request. This topic
describes how to stage your ANSI-271 files so that they are automatically archived and
processed by PC-ACE Pro32, as well as the functions available for viewing, printing,
maintaining and using the archived eligibility benefit response reports.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Eligibility Benefit Response Log" item is not visible on the
"Maintain" menu when performing the steps described in this topic, then this capability
is not available on your installation.
Staging Eligibility Benefit Response Files For Automatic Archiving
At program startup, PC-ACE Pro32 automatically scans separate Institutional and Professional
"staging" directories looking for new ANSI-271 eligibility benefit response files to be archived. If
any ANSI-271 files are present in the staging directories, they are checked for proper format
and archived automatically. In addition, the individual responses are automatically posted to
the original eligibility benefit requests. This automatic archive/post process is also performed
when the Eligibility Benefit Response Log form is opened or when the user manually
refreshes the Eligibility Benefit Response Log list (see next section for details).
On most PC-ACE Pro32 installations, the user will be required to manually copy the ANSI-271
files received from the claims processor into the appropriate staging directory. The Institutional
and Professional staging directories are:
Institutional: winpcace\ansi271\eligub92
Professional: winpcace\ansi271\elig1500
For single-user installations, these directories will reside on the local drive letter to which PCACE Pro32 was originally installed. For multi-user "networked" installations, these directories
will reside on the shared network drive letter to which PC-ACE Pro32 was originally installed.
Attention: Care must be taken to copy Institutional eligibility benefit response files to the
Institutional staging directory, and Professional eligibility benefit response files to the
Professional staging directory. In addition, if your claims processor assigns the same
filename to all ANSI-271 files, you will need to make sure that the most recently staged
eligibility benefit response file has been archived before copying a newer response file
into the staging directory.
Tip: Installations that use data communications scripts to retrieve the ANSI-271
eligibility benefit response files may also automatically copy them to the appropriate
staging directory. Your distributor should be able to confirm whether or not automatic
ANSI-271 file staging will be performed on your installation.
Viewing, Printing & Maintaining Eligibility Benefit Response Files
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Archived ANSI-271 eligibility benefit response files can be viewed and/or printed from the
Eligibility Benefit Response Log form. To view a list of the currently archived ANSI-271 files,
select the "Maintain" and "Eligibility Benefit Response Log" menu items on either the
Institutional or Professional Claims Menu form. The following operations are available:
To view and/or print an archived ANSI-271 response file report, select the desired record
and click the "View Response Report" button (or double-click the desired record). The
report may be printed from the preview form if desired.
To delete an archived ANSI-271 file, select the desired record, click the "Delete" button,
and confirm the deletion.
Note: By default, archived ANSI-271 eligibility benefit response files will be
automatically purged after a certain number of days. Refer to the PC-ACE Pro32
Miscellaneous preferences topic for details on how to change the archive period (or
disable automatic purging altogether, if desired).
Attention: Once an archived ANSI-271 response file has been manually deleted or
automatically purged, the individual responses for the eligibility benefit requests
represented in this file will no longer be available. Be sure to set the ANSI-271
archive period such that eligibility benefit response files remain available long
enough to meet your needs.
To refresh the list of archived ANSI-271 files, click the "Refresh" button. The staging
directory will be re-scanned for the presence of new ANSI-271 files. If new files are
present in the staging directory, they will be checked for proper format, and automatically
archived and posted. The displayed list will then be rebuilt to reflect the current archive
contents.
Tip: You can also right-click the mouse on the desired ANSI-271 archive record to
access all available actions.
Using the Eligibility Benefit Response Reports
The ANSI-271 eligibility benefit response information is presented by PC-ACE Pro32 in a
human-readable report format. The report presents general identification information along
with the eligibility benefit inquiry details returned by the claims processor for all requests. Since
the responses can be viewed for individual eligibility benefit requests from the Eligibility Benefit
Request List Form, this report is typically used as a secondary reference source. There may
be situations in which a response returned by the claims processor cannot be posted to the
original eligibility benefit request. In these situations, you can refer back to this complete ANSI271 eligibility benefit response report for the missing information. Contact your claims
processor's support department for assistance in understanding the ANSI-271 report
nomenclature and eligibility benefit code interpretation.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Eligibility Benefit Request List Form Features" topic for more information on
adding and maintaining eligibility benefit requests.
Refer to the "Preparing eligibility benefit request files for transmission" topic for information
on creating ANSI-270 eligibility benefit request files to send to your claims processor.
Refer to the "Viewing the eligibility benefit response for a specific request" topic for
information on viewing the eligibility benefit response returned for a specific request.
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Viewing the eligibility benefit response for a specific request
When PC-ACE Pro32 archives an ANSI-271 eligibility benefit response file, certain access
information is posted back to each individual eligibility benefit request represented in the
response file. This stored access information makes it possible for users to view and print just
the portion of the ANSI-271 response report that pertains to a single eligibility benefit request.
Note: The patient eligibility benefit request/response capability may not be available on
all installations. If the "Maintain Eligibility Benefit Requests" item is not visible on the
"Maintain" menu when performing the steps described in this topic, then this capability
is not available on your installation.
Responses for individual eligibility benefit requests can be accessed from the Eligibility Benefit
Request List Form. Perform the following steps to access the request list form and view these
response reports:
1) Click either the "Institutional Claims Processing" or "Professional Claims Processing"
button on the PC-ACE Pro32 Main Toolbar to display the respective Claims Menu form.
2) From the Institutional or Professional Claims Menu form, select the "Maintain" and
"Maintain Eligibility Benefit Requests" menu items to open the respective Eligibility
Benefit Request List form.
3) In the Eligibility Request List Filter Options control group, click the "Location:" filter
dropdown list and select the "TR – submitted" location entry. Response reports will only be
available for eligibility benefit requests that have already been submitted (transmitted) .
Tip: The Eligibility Benefit Request List Form displays a "Reply?" column at the far
left when the "TR – submitted" location filter is selected. This column will contain
the value "Yes" for eligibility benefit requests that have responses available.
4) Select the desired eligibility benefit request from the list. Then select the "View Response
For Selected Request" item from the Eligibility Benefit List Form's main "Actions" menu
(or from the convenient right-click popup menu) to preview the response report for this
request. The report may be printed from the preview form if desired.
Note: The "View Response For Selected Request" item will be grayed if no
response has been posted for the selected eligibility benefit request.
Attention: Eligibility benefit responses will be available for individual requests until the
original archived ANSI-271 response file is manually deleted or automatically purged
from the system. The user will be notified when an attempt is made to view a response
which is no longer available. Be sure to set the ANSI-271 archive period such that
eligibility benefit response files remain available long enough to meet your needs. The
archive period can be adjusted from the PC-ACE Pro32 Miscellaneous preferences
form.
Using the Eligibility Benefit Response Reports
The ANSI-271 eligibility benefit response information is presented by PC-ACE Pro32 in a
human-readable report format. The report presents general identification information along
with the eligibility benefit inquiry details returned by the claims processor for the selected
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request. Contact your claims processor's support department for assistance in understanding
the ANSI-271 report nomenclature and eligibility benefit code interpretation.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Eligibility Benefit Request List Form Features" topic for more information on
adding and maintaining eligibility benefit requests.
Refer to the "Preparing eligibility benefit request files for transmission" topic for information
on creating ANSI-270 eligibility benefit request files to send to your claims processor.
Refer to the "Viewing and maintaining eligibility benefit response files" topic for information
on viewing and maintaining the ANSI-271 eligibility benefit response files returned by your
claims processor.
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Adding a new roster billing
New Professional roster billings can be added to PC-ACE Pro32 using either of the following
techniques:
Select the "New Roster Billing" item from the Professional Claims Menu form's main
"Roster" menu. The system will automatically create and display an empty roster billing
form.
Click the "New" button on the Roster Billing List Form. The system will automatically create
and display an empty roster billing form. The new roster billing will automatically be
selected in the list when it is saved.
Professional roster billings are manually entered on the "Professional Roster Billing Form". The
data fields are typically entered in the order presented - from left-to-right and top-to-bottom.
Enter the common roster billing information in the top section of the "Patient Info & General"
tab. Enter patient-specific information for any number of patients in the lower section of this
tab. Enter supplemental information on the "Extended Roster Info" tab if required. Edit
validation errors may be encountered during this entry process if the data entered violates any
of the predefined roster billing edits. Correct any such edit errors and click the "Save" button to
save the roster billing. Roster billings containing unresolved edit errors may be saved if desired
by clicking either the "Save With Errors" button (visible if only non-fatal errors exist) or "Save
With Fatal" button (visible if any fatal errors exist). Only one of these buttons will be visible at
any given time. If neither button is visible, then fatal errors exist on one or more key roster
billing fields. These fatal edit errors must be corrected before the roster billing can be saved.
Note: When a new Professional roster billing is created from the "New Roster Billing"
menu item and saved error-free, you will be prompted to proceed automatically to the
claim generation step. If you choose not to generate the claims at this time (or if the
roster billing was saved with errors), you may generate the claims at a later time from
the Roster Billing List Form.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Institutional & Professional Claims Menus" topic for more information about
the Claims Menu form.
Refer to the "Roster Billing List Form Features" topic for details on using the Professional
Roster Billing List form.
Refer to the "Professional Roster Billing Form" topic for more information on using the
Professional Roster Billing form.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
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Listing, modifying and maintaining roster billings
Professional roster billings in PC-ACE Pro32 are listed, modified, generated, printed, and
otherwise maintained from the Professional Roster Billing List Form. To access this form:
1) Click the "Professional Claims Processing" button on the PC-ACE Pro32 Main Toolbar to
display the Professional Claims Menu form.
2) From the Professional Claims Menu form, select the "Maintain Roster Billings" item from
the main "Roster" menu to open the Professional Roster Billing List Form.
All actions to be performed on a roster billing may be executed from the Roster Billing List
form. Roster billings can be created, viewed/modified, copied, deleted/undeleted, and purged
from the list. In addition, claims may be generated for a selected roster billing and the resulting
roster billing report may be printed from this list. Refer to the "Roster Billing List Form
Features" topic for complete details on the features and operation of the powerful Roster
Billing List form.
Viewing & Modifying Roster Billings
Viewing and/or modifying existing roster billings from the Professional Roster Billing List form
can be performed with these general steps:
1) Use the Roster Billing List form's sorting and filtering capabilities to locate the roster billing
of interest in the list.
2) Select the desired roster billing in the list and click the "View/Update" button to display the
roster billing details in the appropriate roster billing form. Alternatively, just double-click the
desired roster billing record in the list.
3) Make all desired changes to the roster billing. Refer to the Professional Roster Billing Form
topic for details on the many productivity enhancing features available on the powerful
roster billing form.
4) When all changes have been made, click the "Save" button to save the roster billing record
and close the form. Review and correct any edit validation errors as needed. Alternatively,
click the "Cancel" (or "Close") button to cancel any pending roster billing changes.
Generating Roster Billing Claims
A roster billing defines both the common and patient-specific details required to create the
corresponding set of claims. Once you are satisfied with the roster billing contents (and no fatal
edit validation errors exist), you can "generate" claims for this roster billing using either of the
following techniques:
When a new Professional roster billing is created from the "New Roster Billing" menu
item and saved error-free, you will be prompted to proceed automatically to the claim
generation step.
Claims for existing Professional roster billings can be generated from the Roster Billing List
Form. To be eligible for generation, a roster billing must reside in the "to be generated"
(RL) location and have a "clean" (CLN) or "has errors’ (ERR) status. Select the desired
roster billing record and click the "Generate" button (or choose the "Generate Selected
Roster" action) to initiate the claim generation process.
You will be prompted to confirm your intent to generate claims for this roster billing. As the
operation proceeds, running totals of the count and dollar value of all generated claims will be
displayed on the Roster Claim Generation form. You will be notified when the claim generation
operation completes. If desired, click the "View Results" or "View Rejects" buttons to view
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reports of the successfully generated claims or rejected claims, respectively. These reports
can be printed from the report previewer if desired. If any claim rejects occur during the
generation process, the entire process will be reversed. Review the rejects report, correct the
offense, and run the roster billing generation process again. Successfully generated roster
billings will be moved automatically to the "generated" (GR) location.
Tip: The claim billing report for any previously generated roster billing may be previewed
and/or printed by selecting the desired roster billing record in the "Roster Billing List
Form" and choosing the "View Selected Roster Report" action.
Note: PC-ACE Pro32 uses the claim import report preference settings to define the
default reporting options for the roster billing generation process. Refer to the "Printing
Preferences" topic for information on configuring claim import (and roster billing
generation) reports to be printed automatically or to a specific printer.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Roster Billing List Form Features" topic for details on using the Professional
Roster Billing List form.
Refer to the "Professional Roster Billing Form" topic for more information on using the
Professional Roster Billing form.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
Refer to the on-line help "Common Claim Activities" folder for hyperlinks to other claimrelated topics of interest.
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Adding a new Home Health Plan of Care
New Home Health Plans of Care can be added to PC-ACE Pro32 using either of these
techniques:
Select the "Attachments" and "New HH Plan of Care" menu items on the Institutional
Claims Menu form.
Click the "New" button on the Home Health Plan of Care List form. This form can be
accessed by selecting the "Attachments" and "Maintain HH Plans of Care" menu items
on the Institutional Claims Menu form, or by clicking the "Plan of Care" button on the
"Patient" tab of the Reference File Maintenance form. When creating the new Plan of
Care from the patient listing, the Patient Control Number (PCN) and pertinent patient
information for the currently selected patient will be completed automatically.
Plans of Care are entered on the "Home Health Plan of Care Form". The data fields are
typically entered in the order presented - from left-to-right and top-to-bottom - on each tab of
the Plan of Care form. Edit validation errors may be encountered during this entry process if
the data entered violates any of the predefined Plan of Care edits. Correct any such edit errors
and click the "Save" button to save the Plan of Care. Plans of Care containing unresolved edit
errors may be saved if desired by clicking either the "Save With Errors" button (visible if only
non-fatal errors exist) or "Save With Fatal" button (visible if any fatal errors exist). Only one of
these buttons will be visible at any given time. If neither button is visible, then fatal errors exist
on one or more key Plan of Care fields. These key fatal edit errors must be corrected before
the Plan of Care can be saved.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Institutional & Professional Claims Menus" topic for more information about
the Institutional Claims Menu form.
Refer to the "Home Health Plan of Care List Form Features" topic for details on using the
Home Health Plan of Care List form.
Refer to the "Home Health Plan of Care Form" topic for more information on using the
Plan of Care entry form.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
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Listing, modifying and maintaining Plans of Care
Home Health Plans of Care in PC-ACE Pro32 are listed, modified, and otherwise maintained
from the Home Health Plan of Care List form. To access the Plan of Care List form:
1) Click the "Institutional Claims Processing" button on the PC-ACE Pro32 Main Toolbar to
display the Institutional Claims Menu form.
2) From the Institutional Claims Menu form, select the "Attachments" and "Maintain HH
Plans of Care" menu items to open the Home Health Plan of Care List form.
Most actions to be performed on a Plan of Care may be executed from the Plan of Care List
form. Plans of Care can be created, viewed/modified, copied, deleted, and printed from the list.
Refer to the "Home Health Plan of Care List Form Features" topic for complete details on the
features and operation of the powerful Plan of Care List form.
Viewing & Modifying Plans of Care
Viewing and/or modifying existing plans from the Plan of Care List form can be performed with
these general steps:
1) Use the Plan of Care List form's sorting and advanced filtering capabilities to locate the plan
of interest in the list.
2) Select the desired plan in the list and click the "View/Update" button to display the plan
details. Alternatively, just double-click the desired plan record in the list.
3) Make all desired changes to the Plan of Care. Refer to the "Home Health Plan of Care
Form" topic for details on the many productivity enhancing features available on this
powerful form.
4) When all changes have been made, click the "Save" button to save the Plan of Care record
and close the form. Review and correct any edit validation errors as needed. Alternatively,
click the "Cancel" (or "Close") button to cancel any pending plan changes.
Actions On Multiple Plans of Care
Many of the actions available in the Plan of Care List form are applicable to both single
(selected) plans as well as groups of "checked" plans. This powerful multi-selection capability
makes operating on groups of plans a snap! Simply use the Plan of Care List form's advanced
filtering options to narrow the plan list contents down until it contains only the desired plans.
Then select the "Check All Plans of Care" action from the main or popup menu to instantly
mark (i.e., "check") all the plans of interest. A number of actions are available from the main or
popup menu to operate on the entire group of plans in a single session. Refer to the "Home
Health Plan of Care List Form Features" topic for complete details on selecting and acting on
multiple plans at once.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Home Health Plan of Care List Form Features" topic for details on using the
Plan of Care List form.
Refer to the "Home Health Plan of Care Form" topic for more information on using the
Plan of Care entry form.
Refer to the "Claim & Reference File Edit Validation" topic for more information about the
edit validation process and associated forms.
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Printing Home Health Plans of Care
Home Health Plans of Care are printed in PC-ACE Pro32 using an advanced "image overlay"
technique. This advanced method automatically overlays the plan field values onto a graphical
image of the blank Plan of Care (CMS-485/486/487) form, resulting in a complete plan image
that can be printed on stock paper. The image-overlay technique eliminates all the paper
alignment headaches often associated with printing onto pre-printed forms.
Note: Home Health Plan of Care printing requires that the free Adobe Acrobat Reader
(Version 4.0 or later) be installed on your system. This reader is available for download
from Adobe (www.adobe.com). When the Acrobat Reader is properly installed, PCACE Pro32 will automatically detect and configure the path to the ACRORD32.EXE
program.
The steps involved in printing a Plan of Care (or a selection of plans) are as follows:
1) From the PC-ACE Pro32 Main Toolbar, click the "Institutional Claims Processing" button
to open the Institutional Claims Menu form.
2) Select the "Attachments" and "Maintain HH Plans of Care" menu items to display the
Home Health Plan of Care List form. All plan printing is performed from the Plan of Care list.
3) To print a single Plan of Care, simply select the desired plan from the list and select the
"Print Selected Plan of Care" item from the Plan of Care List form's main "Actions" menu
(or convenient right-click popup menu). The Home Health Plan of Care Print Options form
will be displayed.
Tip: To print a selection of plans, simply "check" the desired plans and select the
"Print All Checked Plans of Care" item from the Plan of Care List form's main
"Actions" menu. Refer to the "Home Health Plan of Care List Form Features" topic for
more information on multiple-plan selection.
4) The Home Health Plan of Care Print Options form allows the user to override the default
destination printer and to select the desired Plan of Care forms (i.e., CMS-485 only, CMS486 only, or both if available). Click the "Preview" button to preview the plan(s) before
printing. Click the "Print" button to print the plan(s) without previewing them.
Plan of Care "previewing" employs the Adobe Acrobat Reader. Use the Acrobat Reader's
"print" option to print a previewed plan. When you have previewed and optionally printed
the plan, close the Acrobat Reader program. This will signal PC-ACE Pro32 that you are
ready to continue.
Attention: You will not be able to resume activities in PC-ACE Pro32 until the
Acrobat Reader program has been exited. Simply closing the plan document within
the reader is not enough to signal PC-ACE Pro32 to continue.
5) If you have selected multiple plans, they will be printed in sequence based on the current
Plan of Care List form’s "Sort By:" selection. A progress form will display details about the
plan currently being printed. Click the "Cancel" button on this progress form to cancel the
printing session following the plan currently being printed.
A Few Technical Notes
Here is some additional technical information that you need to know about printing Plans of
Care in PC-ACE Pro32:
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One or more Home Health Plan of Care Addendum (CMS-487) forms will be printed
automatically if needed to handle overflow from both the Home Health Certification And
Plan of Care (CMS-485) and Medical Update And Patient Information (CMS-486) forms.
Home Health Plan of Care printing will be available only if the Adobe Acrobat Reader
(Version 4.0 or later) is properly installed on the system. You must exit PC-ACE Pro32
before installing the Acrobat Reader. A properly installed reader will be detected
automatically the next time PC-ACE Pro32 is started. If necessary, you can manually
configure the Acrobat Reader executable file (ACRORD32.EXE) path from the "Misc" tab
of the PC-ACE Pro32 Preferences form.
Tip: The Adobe Acrobat Reader has its own preference settings that will let you
choose the initial document magnification level and get rid of the splash screen that is
shown by default every time the reader is started.
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The default destination printer for Institutional Claims printing is also used as the Plan of
Care default destination printer. This default can be set from the "Printing" tab of the PCACE Pro32 Preferences form. This default destination printer setting will be used during
Plan of Care print operations unless overridden at print time from the Home Health Plan of
Care Print Options form.
Common Reference File Procedures
Common Reference File Procedures
Adding and maintaining patients
The "Patient" tab of the Reference File Maintenance form provides an interface to add and
maintain patient information, including the patient's primary, secondary, and tertiary insured
details. Setup of the Patient reference file is optional. If you choose to setup patients, the
complete patient list will be accessible during claim entry using the variable-list lookup feature.
When a patient is selected from the lookup list during claim entry, all applicable patient
information will be automatically loaded into the appropriate claim form fields. The Patient tab
provides a convenient "Sort By" selection that quickly sorts the patient list by "Patient PCN" or
"Patient Name". Operations available include:
To add a new patient record, click the "New" button and enter the new patient
information.
To view or modify an existing patient record, select the desired record and click the
"View/Update" button (or double-click the desired record).
To delete an existing patient record, select the desired record, click the "Delete" button,
and confirm the deletion.
To display a list of the Home Health Plans of Care (POCs) on file for an existing patient
record, select the desired record and click the "Plan of Care" button. See the "Listing,
modifying and maintaining Plans of Care" topic for more information.
Tip: The Patient Information form provides several List Filter Options that can be helpful
in locating specific patients. Refer to the "Reference File Maintenance Form" topic for
more discussion of these common filter options.
Entering Patient Information
The Patient Information form provides access to a patient's details on the following information
tabs:
General Information - provides access to general patient information such as the
patient's name, address, birthdate, and various status flags.
Extended Info - provides access to extended patient information such as information on
the patient's legal representative (Professional use only), the primary Provider ID
(Institutional use only), and the Billing and Rendering Provider IDs (Professional use
only).
Primary Insured - provides access to the payer, insured, and employer information for
the primary Institutional and/or Professional payer(s). If your system is licensed for both
Institutional and Professional claim activities, then you will have the option to enter
separate Institutional and Professional insured information. See the "Common vs.
Separate Insured Information?" section below for details.
Secondary Insured - provides access to insured information for the secondary
Institutional and/or Professional payer(s). See the Primary Insured information bullet
above for details.
Tertiary Insured - provides access to insured information for the tertiary Institutional
and/or Professional payer(s). See the Primary Insured information bullet above for
details.
Tip: A number of fields on the Patient/Insured Information tabs support data entry via
fixed-list or variable-list lookups. These lookup lists are accessed by right-clicking the
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mouse over the field or pressing the "F2" key while focused on the field. Helpful "fly-over"
hints are also available for many fields.
Saving & Canceling Patient Updates
After completing data entry on the Patient Information form, click the "Save" button (or type
"<ALT>S") to save and exit the form. Alternatively, click the "Cancel" button to abandon any
changes and exit the form. During the patient save operation, an edit validation process is
performed on all patient record fields. If no edit validation errors occur, the patient record is
saved without further user intervention. If, however, one or more edit validation errors occur,
you will be presented with the Edit Validation Errors List form. This form lists all the edit
validation errors that have occurred, indicating which ones are "fatal" and which are "nonfatal". Refer to the "Claim & Reference File Edit Validation" topic for a more complete
discussion of the reference file edit validation process and the Edit Validation Errors List form.
If any fatal edit errors exist, you must correct them before the patient record can be saved. If
only non-fatal edit errors exist, you will have the option to correct the errors or save the patient
record with errors. Click the "Save With Errors" button to save a patient record that contains
only non-fatal errors. If edit validation errors occur, several "Save" attempts may be required to
correct and save a "clean" patient record.
Common vs. Separate Insured Information?
NOTE: This discussion applies only if your system is licensed for both Institutional and
Professional claim activities. If you are licensed for only a single claim type, the form controls
described in this section will not even be visible in your system.
The Patient reference file is shared between Institutional and Professional claim activities. In
terms of general patient information, this shared approach is satisfactory. However, it is quite
possible that the "payer/insured" information will need to be different when an Institutional
claim is billed for a patient versus when a Professional claim is billed for the same patient. For
example, an Institutional Medicare claim requires that the submission payer have an "MCA"
line of business (LOB), while a Professional Medicare claim requires a submission payer LOB
of "MCB". In order to deal with this need for separate Institutional and Professional
"payer/insured" information sets, the Patient Information form provides the "Insured
Information Options" selection group. This selection group exists on each of the Insured
tabs, and controls whether "common" or "separate" payer/insured information is required. The
available selections include:
Common Inst & Prof - When selected, instructs the system to maintain a single set of
payer/insured information. The same payer/insured information will be brought forward
into both Institutional and Professional claims during the patient lookup process.
Separate Inst & Prof - When selected, instructs the system to maintain separate
payer/insured information sets for Institutional and Professional use. The single Insured
tab will be replaced by separate "(Inst)" and "(Prof)" Insured tabs. The appropriate
payer/insured information will be brought forward into the Institutional or Professional
claim during the patient lookup process.
The decision as to whether "common" or "separate" payer/insured information is required can
be made separately for the primary, secondary, and tertiary Insured tabs.
Related Topics
The following hyperlinks provide additional information related to this topic:
Refer to the "Reference File Maintenance Form" topic for a discussion of the common
reference file form features and filter options.
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Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Adding and maintaining payers
The "Payer" tab of the Reference File Maintenance form provides access to maintain system
payer information. Setup of the Payer reference file is mandatory (although it may be setup in
advance by your distributor). Payers are accessible during claim entry using the variable-list
lookup feature. When a payer is selected from the lookup list during claim entry, all applicable
payer information will be automatically loaded into the appropriate claim form fields. Payers are
uniquely defined by their Payer ID, Line of Business (LOB), and an optional "Usage" flag (see
below). All payers referenced on claims must exist in the Payer reference file, with the
exception of the special "dump" payer (Payer ID=99999). The Payer tab provides a convenient
"Sort By" selection that quickly sorts the payer list by "Payer ID", "Payer Description", "Payer
LOB" or "Payer State". Operations available include:
To add a new payer record, click the "New" button and enter the new payer information.
To view or modify an existing payer record, select the desired record and click the
"View/Update" button (or double-click the desired record).
To create a new payer record that is similar to an existing record, select the desired
payer record, click the "Copy" button, and change only the desired fields. This feature
makes it easy to create multiple payer records for the same payer to support more than
one line of business (LOB).
To delete an existing payer record, select the desired record, click the "Delete" button,
and confirm the deletion.
Tip: The Payer Information form provides several List Filter Options that can be helpful in
locating specific payers. Refer to the "Reference File Maintenance Form" topic for more
discussion of these common filter options.
Entering Payer Information
The Payer Information form provides access to a payer's identification fields (Payer ID, LOB,
and Description), address information, control flags, and optional local fields (defined by the
distributor). The available control flags are defined as follows:
Source - indicates the national payment source code for this payer.
Media - specifies whether the payer receives claims electronically or on paper. The
media flag of a claim’s "submission" payer will determine whether the claim is eligible for
preparation into an EMC file or whether it must be submitted on paper.
Usage - indicates whether the payer record is restricted for Institutional use only,
Professional use only, or unrestricted use. This feature permits Payers for shared LOBs
such as Commercial (COM) to optionally have distinct settings and PrintLink matching
strings for Institutional versus Professional use. If the specified Payer LOB is valid for
only one of these claim types, then the "Usage" value will be forced to the appropriate
setting by the program.
Tip: A number of fields on the Payer Information tab support data entry via fixed-list or
variable-list lookups. These lookup lists are accessed by right-clicking the mouse over
the field or pressing the "F2" key while focused on the field. Helpful "fly-over" hints are
also available for many fields.
Saving & Canceling Payer Updates
After completing data entry on the Payer Information form, click the "Save" button (or type
"<ALT>S") to save and exit the form. Alternatively, click the "Cancel" button to abandon any
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changes and exit the form. During the payer save operation, an edit validation process is
performed on all payer record fields. If no edit validation errors occur, the payer record is
saved without further user intervention. If, however, one or more edit validation errors occur,
you will be presented with the Edit Validation Errors List form. This form lists all the edit
validation errors that have occurred, indicating which ones are "fatal" and which are "nonfatal". Refer to the "Claim & Reference File Edit Validation" topic for a more complete
discussion of the reference file edit validation process and the Edit Validation Errors List form.
If any fatal edit errors exist, you must correct them before the payer record can be saved. If
only non-fatal edit errors exist, you will have the option to correct the errors or save the payer
record with errors. Click the "Save With Errors" button to save a payer record that contains
only non-fatal errors. If edit validation errors occur, several "Save" attempts may be required to
correct and save a "clean" payer record.
PrintLink Matching Descriptions
PrintLink refers to a unique process by which claims can be imported into PC-ACE Pro32
from print image files generated by the user's upstream system. Since the "Payer ID" field for a
claim's primary, secondary, and tertiary payers is not available on the printed claim form, PCACE Pro32 uses a novel "matching" technique to map the "Payer Description" field (which is
available on the printed claim) to the correct payer record in PC-ACE Pro32's Payer reference
file. During the one-time Payer reference file setup process, one or more "matching strings"
should be defined for each payer record. These matching strings are used exclusively to map
print file Payer Descriptions to PC-ACE Pro32 Payer records during the PrintLink claim import
process. Each PrintLink matching string must adhere to one of these 3 formats:
String ends with a "~" (tilde) character - A match is found if the string appears
anywhere in the claim's payer description field.
String ends with a "|" (vertical bar) character - A match is found only if the string
appears at the start of the claim's payer description field. The payer description may
contain additional trailing characters not included in the matching string.
String ends with an alphanumeric character - A match is found only if the string and
the payer description field are identical. The 2 strings must be the same length and
contain exactly the same characters in the same order.
Note: All PrintLink matching string comparisons are case-insensitive.
Click the "PrintLink Matching Descriptions" button while viewing a payer's details to
view/edit the PrintLink matching strings for the selected payer. Click the "New", "Edit", and
"Delete" buttons to add, modify, and delete matching strings for the selected payer record,
respectively. In addition to maintaining the selected payer's matching strings, the user also has
the option to view all currently defined matching string (for all payers) in the order that they will
be searched during the claim import process.
This form also provides a handy "Test Match" feature that allows the user to quickly identify
which payer will be matched to a given print file payer description. To use the test match
feature, select the "Show all strings" radio button, select either the "Institutional" or
"Professional" radio button (if visible), and click the "Test Match" button. Enter the payer
description as it would appear on the printed claim and click the "OK" button. If a match is
found, the matching string record will be highlighted in the list. You will be notified if no match
is found.
Related Topics
The following hyperlinks provide additional information related to this topic:
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Refer to the "Reference File Maintenance Form" topic for a discussion of the common
reference file form features and filter options.
Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Adding and maintaining providers (Institutional)
The "Provider (Inst)" tab of the Reference File Maintenance form provides access to maintain
the providers to be referenced on Institutional claims. NOTE: If you are licensed for Institutional
claim activities only, then this tab will be labeled simply "Provider". Setup of the Institutional
Provider reference file is mandatory if you intend to process Institutional claims. All providers
referenced on Institutional claims must be represented in this reference file. The Provider tab
provides a convenient "Sort By" selection that quickly sorts the Provider list by "LOB",
"Provider Name", "Provider ID", or "Tag". Operations available include:
To add a new provider record, click the "New" button and enter the new provider's
information. If providers already exist in this reference file, you will have the option to
create a completely new provider record, or to inherit and associate the new provider
record with the provider record currently selected in the list. Select the desired creation
options and click the "OK" button to continue. See the discussion below for more
information on provider "inheritance" and "association".
To view or modify an existing provider record, select the desired record from the list and
click the "View/Update" button (or double-click the desired record).
To delete an existing provider record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Attention: Claims are linked to provider records by an internal control number.
Deleting a provider record will irrevocably break any such links that may exist to
claims in the system. The Provider Deletion Confirmation form will be displayed
when you attempt to delete a provider record. This form outlines alternatives to
deletion, and provides a convenient utility to determine how many claims reference
the provider record to be deleted. Consider clearing the "Include In Lookups?"
option on the Institutional Provider Information form as an alternative to deleting
the provider.
Tip: The "Provider (Inst)" tab of the Reference File Maintenance form provides several
list filter options that can be helpful in locating specific providers. Refer to the "Reference
File Maintenance Form" topic for a discussion of these common filter options.
Entering Institutional Provider Information
The Institutional Provider Information form provides access to all Institutional provider fields.
These fields are grouped logically on the following tabs:
General Info - includes fields for the provider name, address, contact, and identification
information (ID, LOB, Payer ID, and tax number).
Extended Info - includes fields for any additional extended provider information (e.g.,
the "pay-to" provider name and address, if different).
Local Fields - includes up to six additional "local" provider fields to be defined by the
distributor. This tab will only be visible if the distributor has defined one or more of these
local fields. Contact your distributor for completion details.
Click the appropriate tab or simply press the "PAGE UP" and "PAGE DOWN" keys to move
between tabs.
Provider records are uniquely defined by the "Provider ID/No." (Provider ID) and "LOB" (Line of
Business) fields, and optionally by the "Payer ID" field as well. These critical fields are defined
as follows:
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Provider ID/No. - The provider identifier to be used on claims for the line of business
specified in the "LOB" field.
LOB - Specifies the line of business applicable to this provider record.
Payer ID - An optional field that, if specified, identifies this provider record as "payerspecific" to the payer identified by this Payer ID.
The "LOB" field value is used to filter the list of providers presented to the user during claim
entry lookup operations. Only provider records with an "LOB" value matching the LOB of the
selected claim payer line will be available for selection.
If required, this provider record's "associations" may be maintained from this form using the
"Select" (adds a new association) and "None" (deletes all associations) buttons adjacent to
the "Provider Associations" listbox.
Tip: A number of fields on the Institutional Provider Information form support data entry
via fixed-list or variable-list lookups. These lookup lists are accessed by right-clicking the
mouse over the field or pressing the "F2" key while focused on the field. Type "<ALT>F2"
(press the "F2" key while holding the "ALT" key down) to identify all fields that support a
lookup list. Press the "ESC" key to disable the flashing notification. Helpful "fly-over" hints
are also available for many fields.
Saving & Canceling Provider Updates
After completing data entry on the Institutional Provider Information form, click the "Save"
button (or type "<ALT>S") to save and exit the form. Alternatively, click the "Cancel" button to
abandon any changes and exit the form. During the provider save operation, an edit validation
process is performed on all provider record fields. If no edit validation errors occur, the provider
record is saved without further user intervention. If, however, one or more edit validation errors
occur, you will be presented with the Edit Validation Errors List screen. This screen lists all the
edit validation errors that have occurred, indicating which ones are "fatal" and which are "nonfatal". Refer to the "Claim & Reference File Edit Validation" topic for a more complete
discussion of the reference file edit validation process and the Edit Validation Errors List
screen. If any fatal edit errors exist, you must correct them before the provider record can be
saved. If only non-fatal edit errors exist, you will have the option to correct the errors or save
the provider record with errors. Click the "Save With Errors" button to save a provider record
that contains only non-fatal errors. If edit validation errors occur, several "Save" attempts may
be required to correct and save a "clean" provider record.
Provider Inheritance and Associations
PC-ACE Pro32 requires that each Institutional provider record be defined for a single line of
business (LOB). As such, if a provider supports multiple LOBs, then separate records for each
are required. This hierarchy results in greatly enhanced flexibility by allowing the user to define
unique IDs and support information (addresses, etc) on a per-LOB basis. If necessary,
provider records may even be defined such that the information is unique to a single payer
within the LOB (by completing the "Payer ID" field on the Institutional Provider Information
form).
In order to link provider records that represent the same entity, PC-ACE Pro32 has introduced
the concept of provider "associations". For example, if Jones Memorial Hospital is an
Institutional provider for Medicare Part A (MCA) and Blue Cross (BC) patients, two separate
provider records must be added. However, since these 2 records really represent the same
provider, they should be "associated" with each other. The Provider tab of the Reference File
Maintenance form provides a convenient "inheritance" option that makes creation of
associated provider records a snap. Simply click the "New" button and create the first Jones
Memorial Hospital provider record from scratch (start with all fields blank), assign the "MCA"
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line of business, complete all applicable fields on the Institutional Provider Information form,
and save the provider record. Then select the newly created provider record in the provider list
and click the "New" button again. When prompted, select the "Inherit name/address
information from the selected provider" option. Also check the "Associate the new
provider with the selected provider" checkbox and click the "OK" button. A duplicate of the
selected provider will be created and displayed. Enter "BC" in the "LOB" field and save the
new provider record. These provider records are now "associated" with each other to reflect
that they represent the same entity. Repeat this "inherit and associate" process to create
additional Jones Memorial Hospital provider records for other LOBs if desired. Associations
are used during the claim preparation process to identify the various lines of business
applicable to a specific provider.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Setup of Medicare Part A Systems" or "Setup of Institutional All-Payer
Systems" topic for a suggested approach to initial setup of the provider reference file.
Refer to the "Reference File Maintenance Form" topic for a discussion of the common
reference file form features and filter options.
Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Adding and maintaining providers (Professional)
The "Provider (Prof)" tab of the Reference File Maintenance form provides access to maintain
the providers to be referenced on Professional claims. NOTE: If you are licensed for
Professional claim activities only, then this tab will be labeled simply "Provider". Setup of the
Professional Provider reference file is mandatory if you intend to process Professional claims.
All providers referenced on Professional claims must be represented in this reference file. The
Provider tab provides a convenient "Sort By" selection that quickly sorts the Provider list by
"LOB", "Type", "Provider/Group Name", "Provider ID", "Group Label", or "Tag". Operations
available include:
To add a new provider record, click the "New" button and enter the new provider's
information. If providers already exist in this reference file, you will have the option to
create a completely new provider record, or to inherit and associate the new provider
record with the provider record currently selected in the list. Select the desired creation
options and click the "OK" button to continue. See the discussion below for more
information on provider "inheritance" and "association".
To view or modify an existing provider record, select the desired record from the list and
click the "View/Update" button (or double-click the desired record).
To delete an existing provider record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Attention: Claims are linked to provider records by an internal control number.
Deleting a provider record will irrevocably break any such links that may exist to
claims in the system. The Provider Deletion Confirmation form will be displayed
when you attempt to delete a provider record. This form outlines alternatives to
deletion, and provides a convenient utility to determine how many claims reference
the provider record to be deleted. Consider clearing the "Include In Lookups?"
option on the Professional Provider Information form as an alternative to deleting
the provider.
Tip: The "Provider (Prof)" tab of the Reference File Maintenance form provides several
list filter options that can be helpful in locating specific providers. Refer to the "Reference
File Maintenance Form" topic for a discussion of these common filter options.
Entering Professional Provider Information
The Professional Provider Information form provides access to all Professional provider fields.
These fields are grouped logically on the following tabs:
General Info - includes fields for the provider type, name, address, contact, identification
(Provider or Group ID/No., LOB, Payer ID, Group Label, tax number), and other
miscellaneous information.
Extended Info - includes fields for any additional extended provider information (e.g.,
the "pay-to" provider name and address, if different).
Local Fields - includes up to six additional "local" provider fields to be defined by the
distributor. This tab will only be visible if the distributor has defined one or more of these
local fields. Contact your distributor for completion details.
Click the appropriate tab or simply press the "PAGE UP" and "PAGE DOWN" keys to move
between tabs.
The Professional provider structure defines 3 distinct provider types:
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Group Practice - Identifies the provider record as representing a group practice for billing
purposes. When creating group provider records, the user must assign a unique "Group
Label" to identify the group. It is assumed that a group provider will be assigned members
(see "Individual in Group" provider type below).
Individual in Group - Identifies the provider record as representing an individual provider
that is a member of one of the existing "group" providers (see "Group Practice" provider
type above). When creating "individual in group" provider records, the user can select the
desired "Group Label" from a lookup list of applicable group providers. Claims may not be
billed directly to "individual in group" providers, rather these providers are specified as
rendering providers on Professional claims.
Solo Practice - Identifies the provider record as representing a solo practice provider.
Solo practice providers are not associated with any provider group, and will bill claims
directly.
Professional claims require a "billing" provider that can be either a "group" or "solo" provider
(but not an "individual in group"). The Professional claim entry provider lookup and claim
editing process will enforce this requirement.
Provider records are uniquely defined by the "Provider ID/No." (Provider ID) and "LOB" (Line of
Business) fields, and optionally by the "Payer ID" field as well. These critical fields are defined
as follows:
Provider ID/No. (or Group ID/No. for "group" providers) - The provider (group) identifier
to be used on claims for the line of business specified in the "LOB" field.
LOB - Specifies the line of business applicable to this provider record.
Payer ID - An optional field that, if specified, identifies this provider record as "payerspecific" to the payer identified by this Payer ID.
The "Provider Type" selection and "LOB" field value are used to filter the list of providers
presented to the user during claim entry lookup operations. Only provider records with an
"LOB" value matching the claim's LOB will be available for selection. Claim billing provider
lookup lists will include only "group" and "solo" providers, while rendering provider lookup lists
will include only "individual in group" providers.
If required, this provider record's "associations" may be maintained from this form using the
"Select" (adds a new association) and "None" (deletes all associations) buttons adjacent to
the "Provider Associations" listbox.
Tip: When setting up provider records for a group and its members, always create the
"Group Practice" provider record(s) first. Associated group provider records must be
created for each line of business (LOB) in which the group (or any of its members) will
participate. Once the group provider records are in place, create "Individual in Group"
provider records for each group member. Associated group member provider records
must then be created for each line of business (LOB) in which the member will
participate. Refer to the "Setup of Professional Systems" topic for a suggested approach
to initial setup of the provider reference file.
Tip: A number of fields on the Professional Provider Information form support data entry
via fixed-list or variable-list lookups. These lookup lists are accessed by right-clicking the
mouse over the field or pressing the "F2" key while focused on the field. Type "<ALT>F2"
(press the "F2" key while holding the "ALT" key down) to identify all fields that support a
lookup list. Press the "ESC" key to disable the flashing notification. Helpful "fly-over" hints
are also available for many fields.
Saving & Canceling Provider Updates
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After completing data entry on the Professional Provider Information form, click the "Save"
button (or type "<ALT>S") to save and exit the form. Alternatively, click the "Cancel" button to
abandon any changes and exit the form. During the provider save operation, an edit validation
process is performed on all provider record fields. If no edit validation errors occur, the provider
record is saved without further user intervention. If, however, one or more edit validation errors
occur, you will be presented with the Edit Validation Errors List screen. This screen lists all the
edit validation errors that have occurred, indicating which ones are "fatal" and which are "nonfatal". Refer to the "Claim & Reference File Edit Validation" topic for a more complete
discussion of the reference file edit validation process and the Edit Validation Errors List
screen. If any fatal edit errors exist, you must correct them before the provider record can be
saved. If only non-fatal edit errors exist, you will have the option to correct the errors or save
the provider record with errors. Click the "Save With Errors" button to save a provider record
that contains only non-fatal errors. If edit validation errors occur, several "Save" attempts may
be required to correct and save a "clean" provider record.
Provider Inheritance and Associations
PC-ACE Pro32 requires that each Professional provider record be defined for a single line of
business (LOB). As such, if a provider supports multiple LOBs, then separate records for each
are required. This hierarchy results in greatly enhanced flexibility by allowing the user to define
unique IDs and support information (addresses, etc) on a per-LOB basis. If necessary,
provider records may even be defined such that the information is unique to a single payer
within the LOB (by completing the "Payer ID" field on the Professional Provider Information
form).
In order to link provider records that represent the same entity, PC-ACE Pro32 has introduced
the concept of provider "associations". For example, if John D. Solo is a Professional solo
provider for Medicare Part B (MCB) and Blue Shield (BS) patients, two separate provider
records must be added. However, since these 2 records really represent the same provider,
they should be "associated" with each other. The Provider tab of the Reference File
Maintenance form provides a convenient "inheritance" option that makes creation of
associated provider records a snap. Simply click the "New" button and create the first John D.
Solo provider record from scratch (start with all fields blank), assign the "MCB" line of
business, complete all applicable fields on the Professional Provider Information form, and
save the provider record. Then select the newly created provider record in the provider list and
click the "New" button again. When prompted, select the "Inherit name/address information
from the selected provider" option. Also check the "Associate the new provider with the
selected provider" checkbox and click the "OK" button. A duplicate of the selected provider
will be created and displayed. Enter "BS" in the "LOB" field and save the new provider record.
These provider records are now "associated" with each other to reflect that they represent the
same entity. Repeat this "inherit and associate" process to create additional John D. Solo
provider records for other LOBs if desired. Associations are used during the claim preparation
process to identify the various lines of business applicable to a specific provider.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Setup of Professional Systems" topic for a suggested approach to initial
setup of the provider reference file.
Refer to the "Reference File Maintenance Form" topic for a discussion of the common
reference file form features and filter options.
Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Maintaining Codes & Miscellaneous Reference Files
Codes & Miscellaneous Reference Files Overview
The "Codes/Misc" tab of the Reference File Maintenance form provides access to many of the
core PC-ACE Pro32 reference files. Most of these files will be pre-loaded and ready for use
when PC-ACE Pro32 is installed. Others are optional and will require setup before use. The
buttons on this tab are grouped as "Shared" (Institutional and Professional), "Institutional" only
and "Professional" only.
The following reference file topics apply to both Institutional and Professional claims:
Submitter File Maintenance - maintain submitter identification and related information
Data Communications File Maintenance - maintain data communications parameters
HCPCS Codes File Maintenance - maintain HCPCS procedure codes and descriptions
HCPCS Modifiers File Maintenance - maintain HCPCS procedure code modifiers,
descriptions, and assignments
ICD9 Codes File Maintenance - maintain ICD-9 diagnosis codes, procedure codes, and
descriptions
Physician (UPIN) File Maintenance - maintain the Physician (UPIN) file
Provider Taxonomy Code File Maintenance - (MISC ANSI) maintain provider taxonomy
codes and classification/specialization descriptions
Claim Adjustment Reason Codes File Maintenance - (MISC ANSI) maintain claim
adjustment reason codes and descriptions
Remittance Remark Codes File Maintenance - (MISC ANSI) maintain remittance remark
codes and descriptions
Eligibility Request Service Type Codes File Maintenance - (MISC ANSI) maintain
eligibility/benefit request service type codes and descriptions
Claim Status Response Codes File Maintenance - (MISC ANSI) maintain claim status
response codes and descriptions
The following reference file topics apply exclusively to Institutional claims:
Type of Bill (TOB) File Maintenance - maintain TOB assignments and related information
Condition/Occurrence/Span/Value Codes File Maintenance - maintain condition,
occurrence, span and value codes, descriptions and assignments
Revenue Codes File Maintenance - maintain revenue codes, descriptions, assignments,
and related information
The remaining reference file topics apply exclusively to Professional claims:
Place of Service (POS) File Maintenance - maintain POS codes, descriptions, and
assignments
Facility File Maintenance - maintain facility information
Charges Master File Maintenance - maintain charge master procedure codes,
descriptions, and charge amounts
Provider Specialty File Maintenance - maintain provider specialty codes and descriptions
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Follow any of the hyperlinks above for more information about the purpose and maintenance of
these core reference files.
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Submitter File Maintenance
Submitter Information in PC-ACE Pro32 is maintained from the Submitter Setup form for both
Institutional and Professional claim types. Information from the Submitter reference file is
required during preparation of Electronic Media Claims (EMC) files. As such, at least one
default submitter record (LOB = "<<ALL>>" ; Payer ID = "<<ALL>>") must be created before
claims can be prepared. Additional LOB/Payer-specific submitter records may also be created
if required (see discussion later in this topic for more details).
If your installation is licensed for both Institutional and Professional claim activities, you must
first select the appropriate claim type from the "Institutional" or "Professional" radio buttons
near the top of this tab. If you are licensed for only one of these claim types, this selection will
not be available.
The maintenance options available on this form include:
To add a new submitter record, click the "New" button and enter the required submitter
information.
To view or modify an existing submitter record, select the desired record from the list and
click the "View/Update" button (or double-click the desired record).
To copy an existing submitter record, select the record to be copied from the list and
click the "Copy" button. This copy feature provides a convenient means of creating new
LOB/Payer-specific submitter records. Enter the desired LOB and/or Payer ID and make
any other required changes to the copied fields.
To delete a submitter record, select the desired record from the list, click "Delete" button,
and confirm the deletion.
Entering Submitter Information
The Submitter Information form contains three tabs:
General - specifies the LOB (line of business), Payer ID, submitter name, address and
IDs.
Prepare - specifies flags used to control the claim preparation process as well as
information to be placed directly in the EMC transmission file. The currently defined
prepare control fields include:
Include Error Claims - specifies whether claims with non-fatal errors will be
included in the electronic transmission file by default. This default setting may be
overridden when the claims are prepared.
Submission Status - specifies if the electronic transmission file will be flagged as a
"Production" or a "Test" file by default. This default setting may be overridden when
the claims are prepared.
EMC Output Format - specifies the default electronic file format. Only the ANSI-837
format is currently supported.
ANSI Version (837) (institutional only) - specifies the desired version of the
institutional ANSI-837 transmission file. You should change this value only under
instructions from your distributor.
ANSI Ver (837 Prof) (professional only) - specifies the desired version of the
professional ANSI-837 transmission file. You should change this value only under
instructions from your distributor.
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ANSI Ver (837 Dent) (professional only) - specifies the desired version of the dental
ANSI-837 transmission file. You should change this value only under instructions
from your distributor.
ANSI Version (270) - specifies the desired version of the ANSI-270 eligibility benefit
request file (if this feature is enabled on your installation). You should change this
value only under instructions from your distributor.
ANSI Version (276) - specifies the desired version of the ANSI-276 claim status
request file (if this feature is enabled on your installation). You should change this
value only under instructions from your distributor.
EMC File - specifies the desired EMC filename using the standard DOS 8.3 naming
convention. Leave this field blank to use the default EMC filename.
Vendor - specifies an optional Vendor number required by some distributors.
Intermediary - specifies the unique Intermediary (distributor) identification number
of the organization processing your electronic claims. This identifier is used to trigger
distributor-specific claim prepare rules.
Next Serial No. - specifies the next Serial Number to be assigned during the
prepare process. This value is automatically updated each time claims are prepared.
Next File Seq. (Institutional only) - specifies the next File Sequence Number to be
assigned during the prepare process. This value is automatically updated each time
claims are prepared.
Force Separate Prepare – specifies whether or not claims for the LOB and/or Payer
ID combination specified on this Submitter record are to be prepared separately from
all other claims. Use this option to insure that restricted groups of claims are not
inadvertently included in prepare runs containing claims outside of the restricted
group. This advanced feature should typically be used only when instructed to do so
by your distributor. The "Force Separate Prepare" option may not be available on all
installations, and will not override any permanent prepare restrictions defined by the
distributor.
ANSI Info - specifies flags and data element values to be used exclusively during the
preparation of transmission files in ANSI-837 format. The currently defined ANSI
information fields include:
Submitter Interchange ID Qualifier - specifies the system/method of code structure
used to designate the Submitter ID in all electronic interchanges. This qualifier
populates element ISA05 of the Interchange Control Header (ISA) segment in the
ANSI-837 format EMC file. The distributor will provide this qualifier if required.
Receiver Interchange ID Qualifier - specifies the system/method of code structure
used to designate the Receiver ID in all electronic interchanges. This qualifier
populates element ISA07 of the Interchange Control Header (ISA) segment in the
ANSI-837 format EMC file. The distributor will provide this qualifier if required.
Authorization Info - specifies optional Interchange Sender Authorization or
identification information. This value populates element ISA02 of the Interchange
Control Header (ISA) segment in the ANSI-837 format EMC file.
Security Info - specifies optional Interchange Sender Security information. This
value populates element ISA04 of the Interchange Control Header (ISA) segment in
the ANSI-837 format EMC file.
Acknowledgment Requested – specifies whether or not an interchange
acknowledgment (TA1) is requested. This value populates element ISA14 of the
Common Reference File Procedures
Interchange Control Header (ISA) segment in the ANSI-837 format EMC file. You
should change this value only under instructions from your distributor.
Additional EDI Submitter Contact Information – specifies up to three (3)
additional EDI communication.numbers for the person in the submitter organization
who deals with data transmission issues. Each number has a corresponding "type"
field to identify the number's purpose. This information populates the "Submitter EDI
Contact Information" (PER) segment in the ANSI-837 format EMC file.
Note: Use the "TE – Telephone" and "FX – Facsimile" contact types only if an
alternate phone/fax number is needed. The primary phone and/or fax number
should always be entered in the fields provided on the "General" tab.
ANSI Info (2) - specifies optional data element override values to be used exclusively
during the preparation of transmission files in ANSI-837 format. Leave these override
fields empty for default ANSI-837 processing. You should change these values only
under instructions from your distributor. The currently defined ANSI-837 override fields
include:
Interchange Sender ID (ISA06) - specifies the Interchange Sender ID override
value. This value populates element ISA06 of the Interchange Control Header (ISA)
segment in the ANSI-837 format EMC file.
Interchange Receiver ID (ISA08) - specifies the Interchange Receiver ID override
value. This value populates element ISA08 of the Interchange Control Header (ISA)
segment in the ANSI-837 format EMC file.
Application Sender's Code (GS02) - specifies the Application Sender's Code
override value. This value populates element GS02 of the Functional Group Header
(GS) segment in the ANSI-837 format EMC file.
Application Receiver's Code (GS03) - specifies the Application Receiver's Code
override value. This value populates element GS03 of the Functional Group Header
(GS) segment in the ANSI-837 format EMC file.
Submitter Primary Identifier (NM109/1000A) - specifies the Submitter Primary
Identifier override value. This value populates element NM109 of the Submitter
Name (NM1) segment in the Submitter Name (1000A) loop in the ANSI-837 format
EMC file.
Receiver Name (NM103/1000B) - specifies the Receiver Name override value. This
value populates element NM103 of the Receiver Name (NM1) segment in the
Receiver Name (1000B) loop in the ANSI-837 format EMC file.
Receiver Primary Identifier (NM109/1000B) - specifies the Receiver Primary
Identifier override value. This value populates element NM109 of the Receiver Name
(NM1) segment in the Receiver Name (1000B) loop in the ANSI-837 format EMC
file.
ANSI Info (3) - specifies optional data element override values to be used exclusively
during the preparation of patient eligibility/benefit request files in ANSI-270 format. This
tab will only be available if the ANSI-270/271 Eligibility Benefit Request/Response
feature is enabled on your installation. Leave these override fields empty for default
ANSI-270 processing. You should change these values only under instructions from your
distributor. The currently defined ANSI-270 override fields include:
Intchg Sender ID/Qual (ISA06/05) - specifies the Interchange Sender ID and ID
Qualifier override values. These values populate elements ISA06 and ISA05 of the
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Interchange Control Header (ISA) segment in the ANSI-270 format EMC file,
respectively.
Intchg Receiver ID/Qual (ISA08/07) - specifies the Interchange Receiver ID and ID
Qualifier override values. These values populate elements ISA08 and ISA07 of the
Interchange Control Header (ISA) segment in the ANSI-270 format EMC file,
respectively.
Application Sender's Code (GS02) - specifies the Application Sender's Code
override value. This value populates element GS02 of the Functional Group Header
(GS) segment in the ANSI-270 format EMC file.
Application Receiver's Code (GS03) - specifies the Application Receiver's Code
override value. This value populates element GS03 of the Functional Group Header
(GS) segment in the ANSI-270 format EMC file.
ANSI Info (4) - specifies optional data element override values to be used exclusively
during the preparation of claim status request files in ANSI-276 format. This tab will only
be available if the ANSI-276/277 Claim Status Request/Response feature is enabled on
your installation. Leave these override fields empty for default ANSI-276 processing. You
should change these values only under instructions from your distributor. The currently
defined ANSI-276 override fields include:
Intchg Sender ID/Qual (ISA06/05) - specifies the Interchange Sender ID and ID
Qualifier override values. These values populate elements ISA06 and ISA05 of the
Interchange Control Header (ISA) segment in the ANSI-276 format EMC file,
respectively.
Intchg Receiver ID/Qual (ISA08/07) - specifies the Interchange Receiver ID and ID
Qualifier override values. These values populate elements ISA08 and ISA07 of the
Interchange Control Header (ISA) segment in the ANSI-276 format EMC file,
respectively.
Application Sender's Code (GS02) - specifies the Application Sender's Code
override value. This value populates element GS02 of the Functional Group Header
(GS) segment in the ANSI-276 format EMC file.
Application Receiver's Code (GS03) - specifies the Application Receiver's Code
override value. This value populates element GS03 of the Functional Group Header
(GS) segment in the ANSI-276 format EMC file.
Payer ID/Qual (NM109/08/2100A) - specifies the Payer Primary Identifier and ID
Qualifier override values. These values populate elements NM109 and NM108 of the
Payer Name (NM1) segment in the Payer Name (2100A) loop in the ANSI-276
format EMC file, respectively.
Info Rcvr ID/Qual (NM109/08/2100B) - specifies the Information Receiver Primary
Identifier and ID Qualifier override values. These values populate elements NM109
and NM108 of the Information Receiver Name (NM1) segment in the Information
Receiver Name (2100B) loop in the ANSI-276 format EMC file, respectively.
Local fields - specifies up to six additional submitter fields to be defined by the
distributor. This tab will only be visible if the distributor has defined one or more of these
local fields. Contact your distributor for completion details.
Tip: A number of fields on the Submitter Information form support data entry via fixed-list
and variable-list lookups. These lookup lists are accessed by right-clicking the mouse
over the field or pressing the "F2" key while focused on the field.
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Attention: You should add and/or modify submitter information only under the
supervision of your distributor or an authorized technical support specialist. Incorrectly
configuring submitter records will result in EMC file incompatibilities.
Saving & Canceling Submitter Updates
After completing data entry on the Submitter Information form, click the "Save" button (or type
"<ALT>S") to save and exit the form. Alternatively, click the "Cancel" button to abandon any
changes and exit the form. During the submitter save operation, an edit validation process is
performed on all submitter record fields. If no edit validation errors occur, the submitter record
is saved without further user intervention. If, however, one or more edit validation errors occur,
you will be presented with the Edit Validation Errors List form. This form lists all the edit
validation errors that have occurred, indicating which ones are "fatal" and which are "nonfatal". Refer to the "Claim & Reference File Edit Validation" topic for a more complete
discussion of the reference file edit validation process and the Edit Validation Errors List form.
If any fatal edit errors exist, you must correct them before the submitter record can be saved. If
only non-fatal edit errors exist, you will have the option to correct the errors or save the
submitter record with errors. Click the "Save With Errors" button to save a submitter record
that contains only non-fatal errors. If edit validation errors occur, several "Save" attempts may
be required to correct and save a "clean" submitter record.
LOB/Payer-Specific Submitter Records
In addition to the default submitter record, the Submitter Setup form allows you to create
submitter records that are specific to a particular line-of-business (LOB), a particular Payer ID,
or a combination of LOB and Payer ID. This feature provides flexibility in cases where the
submitter information to be included in the EMC file varies depending on the LOB and/or Payer
ID. For example, you might use this feature if you are required to prepare and submit your
Medicare (MCA/MCB) claims to a different claims processor than claims for other LOBs.
Likewise, you might have a requirement to define unique submitter identification information
(Submitter ID, address, etc) for a specific LOB and Payer ID combination.
When the prepare process generates a new submitter record, the Submitter reference file is
searched for the most specific match available. For example, assume that a Submitter
reference file record for LOB = "MCA" and Payer ID = "12345" is defined (in addition to the
always-present default record which has empty LOB and Payer ID values). When the EMC file
submission header for a batch of "MCA" claims for Payer ID "12345" is to be built, then the
information in this "MCA/12345-specific" reference file record will be used. Submission
headers for claims with LOB = "MCA" and Payer IDs other than "12345" (as well as claims for
all other LOBs) will use the default Submitter reference file record.
Note: If desired, the "Intermediary" value may be specified on LOB-specific and/or
Payer-specific submitter records. This feature is useful to control custom prepare and
claim-printing rules defined by a particular distributor. If the "Intermediary" value is left
blank (default value) on an LOB-specific and/or Payer-specific submitter record, then
the value specified on the next least-specific submitter record will be used. The
"Intermediary" value on the default submitter record serves as the "last resort" value.
The "Intermediary" values should be modified only when directed to do so by your
distributor.
Related Topics:
The following hyperlinks provide additional information related to this topic:
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Refer to the "Preparing claims for transmission" topic for more information on preparing
electronic claim files.
Refer to the "Reference File Maintenance Form" topic for a discussion of the common
reference file form features and filter options.
Refer to the "Claim & Reference File Edit Validation" topic for a discussion of the edit
validation process.
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Data Communications File Maintenance
Data communications information in PC-ACE Pro32 is maintained from the Data
Communications Setup form for both Institutional and Professional claim types. This reference
file defines the data communication parameter values to be made available to an external data
communications program.
If your installation is licensed for both Institutional and Professional claim activities, you must
first select the appropriate claim type from the "Institutional" or "Professional" radio buttons
near the top of this tab. If you are licensed for only one of these claim types, this selection will
not be available.
The Data Communications Setup form provides the following maintenance options:
To add a new data communications record, click the "New" button and enter the desired
information on the Data Communication Information form.
To view or modify an existing data communications record, select the desired record
from the list and click the "View/Update" button (or double-click the desired record).
To copy an existing data communications record, select the desired record from the list
and click the "Copy" button. The copy feature provides a convenient means of creating
new LOB-specific or LOB/Payer-specific data communications records. Enter the desired
LOB (and optional Payer ID) and make any other required changes to the copied fields.
To delete an existing data communications record, select the desired record from the list,
click the "Delete" button, and confirm the deletion.
Entering Data Communications Information
The Data Communication Information Form contains three tabs:
General - specifies the LOB, optional Payer ID and a description of this data
communications record.
Host Info - specifies up to 3 distributor defined data communications variables as well
as several "Host Phone" fields. The distributor receiving your electronic claims
transmission will define the communications variable names and content requirements.
Local - specifies up to six additional data communications fields to be defined by the
distributor. This tab will only be visible if the distributor has defined one or more of these
local fields. Contact your distributor for completion details.
Attention: You should add and/or modify data communications information only under
the supervision of your distributor or an authorized technical support specialist.
Incorrectly configuring data communications records will result in EMC file transmission
problems.
LOB & Payer-Specific Data Communications Records
In addition to the default record, the Data Communications Setup form allows you to create
data communications records that are specific to a particular line-of-business (LOB) or a
specific LOB/Payer combination. This feature provides flexibility in cases where the claims for
specific LOBs and/or payers must be transmitted to different locations. For example, you might
use this feature if you are required to prepare and submit your Medicare (MCA/MCB) claims to
a different physical location than claims for other LOBs. Read the Data Communications
Control File section below to see how these specific data communications records are used.
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The Data Communications Control File
Transmission of the electronic claim files generated by PC-ACE Pro32 will be performed by a
third party communications package. The Data Communications Options form provides
"launch" buttons by which users can initiate claims transmission, terminal emulation sessions,
or any other data communication function defined by your distributor. Each time any of these
data communications launch buttons are clicked, PC-ACE Pro32 automatically creates a Data
Communications Control File containing applicable parameters from the Data
Communications reference file. This control file will be located in the server's "winpcace"
directory, and will be named "bcdatcom.dat" for Institutional claim activities and
"bsdatcom.dat" for Professional claim activities.
Note: Actually, both the Institutional and Professional Data Communications Control
Files are created each time any of the launch buttons are clicked. This approach
relieves PC-ACE Pro32 from needing to know whether a certain launch button is
configured as an Institutional activity, a Professional activity, or an activity common to
both claim types. If your system is licensed for a single claim type, then only the
appropriate control file will be created.
The Data Communications Control File can be read by the external data communications
program to obtain the needed transmission parameters (phone number, password, etc.). The
layout of this control file is defined in a separate document, and is available to distributors or
facilities developing their own data communications scripts.
As explained earlier in this topic, the Data Communications reference file supports multiple
records defined for specific LOB and/or LOB/Payer combinations. For example, a Data
Communications record can be defined for LOB = "MCA" and Payer = "00190". Another might
be defined for LOB = "MCA" and no Payer (i.e., left empty). The Data Communications Control
File will be built using data from the record that most precisely describes the filter options used
to prepare the current EMC file. For example, if the last EMC file was prepared to include only
claims for LOB = "MCA" and Payer ID = "00190", then the Data Communications reference file
will be searched for a record specific to this LOB/Payer combination. Since this record exists in
our example, it would serve as the source for the data communications parameters written to
the control file. If instead, the last EMC file was prepared for LOB = "MCA" and any other
Payer ID (or all payers), then the Data Communications reference file record for LOB = "MCA"
and Payer = "" (unspecified) would be used. Finally, if the last EMC file was build with no filter
selections, or with and LOB selection of anything other than "MCA", then the default Data
Communication reference file record (LOB = "" and Payer = "") would be used.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Preparing claims for transmission" topic for more information on preparing
electronic claim files.
Refer to the "Transmitting electronic claim files" topic for a typical example of how the data
communications launch facility can be used.
Refer to the "Data Communication Preferences" topic for information on configuring the
Data Communication Options form "launch" buttons.
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HCPCS Codes File Maintenance
The HCPCS Codes form provides an interface to maintain the HCPCS codes used in PC-ACE
Pro32. Separate database files are used to maintain "global" versus "local" HCPCS codes.
Global HCPCS codes are maintained and updated by your distributor. Changes to global
HCPCS codes should be rare, and should always be performed under a distributor's
supervision. Local HCPCS codes, if any, can be maintained by the distributor or user and
include any additional HCPCS codes valid in your area (but not included in the global list).
Select the "Global codes" or "Local codes" radio button to display the desired list. Then
perform one of the following functions.
To add a new HCPCS code, click the "New" button and enter the new HCPCS code
information. Enter the effective date range using a 4-digit year format.
To view or modify an existing HCPCS code, select the desired code from the list and
click the "View/Update" button (or double-click on the desired code).
To delete an existing HCPCS code, select the desired code from the list, click the
"Delete" button, and confirm the deletion.
Tip: The HCPCS Codes form provides several List Filter Options that can be helpful in
locating specific codes. Refer to the "Reference File Maintenance Form" topic for more
discussion of these common filter options.
Effective Date Range
The Effective Date Range dates are compared to the claim's date of service range during the
claim edit validation process. If the effective date range for a HCPCS code falls outside the
claim's service date range, an edit validation error will be reported. If the effective date range is
left blank, the HCPCS code is valid for all dates of service. If the start date is completed but the
end date is left blank, the HCPCS is valid for all dates of service from (and including) the start
date forward. If the start date is left blank but the end date is completed, the HCPCS code is
valid for all dates of service up to (and including) the end date.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "HCPCS Modifiers File Maintenance" topic for information on maintaining
HCPCS code modifiers and their assignments.
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HCPCS Modifiers File Maintenance
The HCPCS Modifiers form provides an interface to maintain the HCPCS modifiers and their
assignments. HCPCS modifiers and assignments are pre-loaded and should require minimal
maintenance. The HCPCS Modifiers form includes two tabs:
Descriptions - displays a list of HCPCS modifiers and their descriptions. Maintenance
operations available include:
To add a modifier, click the "New" button and enter the new modifier information.
Enter the effective date range using a 4-digit year format.
To view or modify an existing HCPCS modifier, select the desired modifier from the
list and click the "View/Update" button (or double-click the desired HCPCS modifier
in the list).
To delete a HCPCS modifier, select the desired modifier from the list, click the
"Delete" button, and confirm the deletion.
Assignments - defines the list of valid modifiers for each line of business (LOB). These
assignments will also determine which modifiers will be included in the modifier lookup
lists presented during claim entry. The modifier assignment maintenance options include:
Select LOB - filters the assignment list to include only assignments for a specific line
of business. When a specific LOB is selected, it will be used as the default LOB for
new HCPCS modifier assignments.
To add a new modifier assignment, click the "New" button on the Assignments tab.
On the HCPCS Modifier Assignment form, select (or change) the LOB and select a
valid modifier from the drop-down list. Specify the claim type(s) for which this
LOB/modifier assignment is to be considered valid. The validity selections are
defined as follows:
Valid for Inst claims - specifies whether the modifier is valid for use on
Institutional claims for the specified LOB.
When checked, the modifier will be considered valid for use on Institutional
claims for the specified LOB. This modifier will be included in claim entry
lookup lists for the specified LOB. The validity of this modifier may also be
checked during the claim edit validation process.
When unchecked, the modifier will not be considered valid for use on
Institutional claims for the specified LOB.
Valid for Prof claims - specifies whether the modifier is valid for use on
Professional claims for the specified LOB.
When checked, the modifier will be considered valid for use on Professional
claims for the specified LOB. This modifier will be included in claim entry
lookup lists for the specified LOB. The validity of this modifier may also be
checked during the claim edit validation process.
When unchecked, the modifier will not be considered valid for use on
Professional claims for the specified LOB.
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To view or modify an existing HCPCS modifier assignment, select the desired
modifier from the list and click the "View/Update" button (or double-click the desired
HCPCS modifier). Only the "Valid" flags may be modified.
To delete a HCPCS modifier assignment, select the desired modifier assignment
from the list, click the "Delete" button, and confirm the deletion.
Common Reference File Procedures
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "HCPCS Codes File Maintenance" topic for information on maintaining
HCPCS codes.
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ICD9 Codes File Maintenance
The ICD9 Codes form provides an interface to maintain the ICD-9 diagnosis and procedure
codes used in PC-ACE Pro32. These codes are pre-loaded and should not require frequent
additions or modifications. Select the desired radio button to display either the "Diagnosis
codes" list or the "Procedure codes" list. The following maintenance options are available:
To add a new ICD-9 code, click the "New" button and enter the new code's information.
Enter the effective date range using a 4-digit year format.
To view or modify an existing ICD-9 code, select the desired code from the list and click
the "View/Update" button (or double-click the selected ICD-9 code).
To delete an ICD-9 code, select the desired code from the list, click the "Delete" button,
and confirm the deletion.
Tip: The ICD9 Codes form provides several List Filter Options that can be helpful in
locating specific codes. Refer to the "Reference File Maintenance Form" topic for more
discussion of these common filter options.
Effective Date Range
The Effective Date Range dates are compared to the claim's date of service range during the
claim edit validation process. If the effective date range for an ICD-9 code falls outside the
claim's service date range, an edit validation error will be reported. If the effective date range is
left blank, the ICD-9 code is valid for all dates of service. If the start date is completed but the
end date is left blank, the ICD-9 code is valid for all dates of service from (and including) the
start date forward. If the start date is left blank but the end date is completed, the ICD-9 code is
valid for all dates of service up to (and including) the end date.
POA Exempt?
The "POA Exempt?" field is a Y/N indicator displayed for diagnosis codes only. It's purpose is
to identify the diagnosis code as exempt from Present On Admission (POA) reporting
requirements, if applicable. The POA exempt status of standard diagnosis codes is maintained
by the software manufacturer. This field is accessible to the user only to respond in situations
where the POA exempt status might need to be changed during an interim period prior to the
next scheduled product update. Enter a "Y" in this field for diagnosis codes which are exempt
from POA reporting. Enter a "N" or leave the field empty for non-exempt diagnosis codes.
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Physician (UPIN) File Maintenance
The Physician Setup form provides an interface to maintain the optional Physician (UPIN)
reference file. The list of physicians (and associated ID / UPIN, address, and miscellaneous
information) is made available via lookups to speed the claim entry process. The following
maintenance operations can be performed:
To add a new Physician record, click the "New" button and enter the new physician
information.
To view or modify an existing Physician record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To delete a Physician record, select the desired record from the list, click the "Delete"
button, and confirm the deletion.
Tip: A convenient "Sort By" feature quickly sorts the Physician's list by "Name" or
"Physician ID". The Physician Setup form also provides several List Filter Options that
can be helpful in locating specific physician records. Refer to the "Reference File
Maintenance Form" topic for more discussion of these common filter options.
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Type of Bill (TOB) File Maintenance
The Type of Bill (TOB) Codes form provides an interface to maintain the Type of Bill (TOB)
codes used in PC-ACE Pro32. TOB codes apply exclusively to Institutional claims. The TOB
codes are pre-loaded and should not require frequent additions or modifications. The following
maintenance operations can be performed:
Select LOB - filters the list to include only valid TOBs for a specific line of business.
When a specific LOB is selected, it will be used as the default LOB for new TOB code
assignments.
To add a new TOB record, click the "New" button and enter the new TOB information.
On the Type of Bill (TOB) Information form, select (or change) the LOB in the drop-down
list and enter a valid TOB (first 2 positions only). Identify the TOB assignment as either
"Inpatient" or "Outpatient" by selecting the appropriate Patient Category radio button.
To delete a TOB record, select the desired record from the list, click the "Delete" button,
and confirm the deletion.
Note: To modify an existing TOB record, you must delete the existing record and add a
new record with the correct information.
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Condition/Occurrence/Span/Value Codes File Maintenance
The Condition/Occurrence/Span/Value Codes form provides an interface to maintain the
condition/occurrence/span/value codes and assignments. This reference file applies
exclusively to Institutional claims. These codes are pre-loaded and should not require frequent
additions or modifications. The Condition/Occurrence/Span/Value Codes form includes two
tabs:
Descriptions - displays a list of Condition/Occurrence/Span/Value codes and
descriptions. Maintenance operations available include:
Type - filters the Condition/Occurrence/Span/Value code list to include only those
codes of the specified type.
To add a Condition/Occurrence/Span/Value code, click the "New" button and enter
the new code information.
To view or modify an existing Condition/Occurrence/Span/Value code record, select
the desired record and click the "View/Update" button (or double-click the desired
record).
To delete a Condition/Occurrence/Span/Value Code record, select the desired record
from the list, click the "Delete" button, and confirm the deletion.
Codes/TOB - displays a list of valid code assignments for specific Line of Business (LOB),
code type, and Type of Bill (TOB) combinations. Code assignments for a specific code
type (Condition, Occurrence, Span, or Value) are made for each applicable LOB/TOB
combination. These assignments are used to filter the code lookup lists during Institutional
claim entry and to define the acceptable list of codes during the claim edit validation
process. To display the current list of valid code assignments for a specific LOB/TOB
combination, select the desired LOB, Type, and TOB. After a selection is made, the
maintenance operations available will include:
To add a Condition/Occurrence/Span/Value code assignment record for the selected
LOB/Type/TOB combination, click the "New" button and select the new code from the
drop-down list.
To delete a code assignment record for the selected LOB/Type/TOB combination,
select the desired record from the list, click the "Delete" button, and confirm the
deletion.
To delete all code assignment records for the selected LOB/Type/TOB combination,
click the "Delete All" button, and confirm the deletion.
To copy an existing set of code assignment records from a specified source
LOB/Type/TOB combination into the assignment list for the currently specified
LOB/Type/TOB combination, select the desired destination LOB/Type/TOB and click
the "Copy" button. Select the code assignments set from which to copy on the Code
Assignments Copy Source form, click the "Copy" button, and confirm the copy
request. If required, you may then add/delete code assignment records to/from the
newly created list.
Note: The TOB drop-down list on the Codes/TOB tab will include only valid TOBs
for the selected LOB. Refer to the "Type of Bill (TOB) File Maintenance" topic for
information on maintaining the list of valid TOBs for each line of business.
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Revenue Codes File Maintenance
The Revenue Codes form provides an interface to maintain the revenue codes used in PCACE Pro32. Revenue codes apply exclusively to Institutional claims. They are pre-loaded and
should require minimal maintenance. The Revenue Code form displays the current list of
revenue codes, their descriptions and an indication of whether or not revenue code
assignment details exist for this code. Maintenance operations available include:
To add a revenue code, click the "New" button and enter the new revenue code
information. Enter the effective date range using a 4-digit year format.
To view or modify an existing revenue code record, select the desired record from the list
and click the "View/Update" button (or double-click the desired record).
To delete a revenue code record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
To view revenue code assignment details, select the desired record from the list and
click the "TOB Detail" button. See the "Revenue Code Assignments" discussion later in
this topic for more information.
Tip: The Revenue Codes form provides several List Filter Options that can be helpful in
locating specific codes. Refer to the "Reference File Maintenance Form" topic for more
discussion of these common filter options.
Effective Date Range
The Effective Date Range dates are compared to the claim's date of service range during the
claim edit validation process. If the effective date range for a revenue code falls outside the
claim's service date range, an edit validation error will be reported. If the effective date range is
left blank, the revenue code is valid for all dates of service. If the start date is completed but
the end date is left blank, the revenue code is valid for all dates of service from (and including)
the start date forward. If the start date is left blank but the end date is completed, the revenue
code is valid for all dates of service up to (and including) the end date.
Revenue Code Assignments
The Revenue Code Assignments form provides an interface to maintain optional assignment
details for a specific revenue code. If no details exist for a specific revenue code, then the code
will be considered valid for all LOBs and the various flags (described below) will assume their
default values. Maintenance operations available on the Revenue Code Assignments form
include:
To add a new revenue code assignment record, click the "New" button and enter the
desired information on the Revenue Code Assignment Information form.
To view or modify an existing revenue code assignment record, select the desired record
and click the "View/Update" button (or double-click the desired record).
To delete a revenue code assignment record, select the desired record, click the
"Delete" button, and confirm the deletion.
To copy all revenue code assignments records from another revenue code, click the
"Copy" button and enter the revenue code from which the assignment records are to be
copied. This feature makes it easy to duplicate assignment record sets from one revenue
code to another.
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The Revenue Code Assignments Information form provides the following assignment detail
fields:
LOB - specifies the Line of Business (LOB) for which this assignment applies. If the "<< All
LOBs >>" option is selected, then this assignment will apply to all LOBs.
TOB - specifies the Type of Bill (TOB) for which this assignment applies. If this field is left
blank, then this assignment will apply to all TOBs. Only the first 2 characters of the TOB
are required.
Tip: Two special TOB values are available to make it easier to define Revenue Code
Assignments applicable to inpatient or outpatient claims. Enter "IP" in the TOB field
to indicate that the assignment applies to all "inpatient" TOBs. Alternatively, enter
"OP" in this field to indicate that the assignment applies to all "outpatient" TOBs. The
inpatient/outpatient designations for all TOBs are defined in the Type of Bill (TOB)
Maintenance File. Revenue Code Assignments that use these special
inpatient/outpatient designators will automatically adapt to changes in the Type of Bill
Maintenance File.
Control Settings - includes control flags which describe the assignment as follows:
Valid - Determines the validity of the revenue code for claims having the specified
LOB/TOB combination. (Default = Valid)
When checked, the revenue code is valid for claims having the specified
LOB/TOB combination.
When unchecked, the revenue code is not valid for claims having the specified
LOB/TOB combination. The remaining Control Setting flags will be ignored.
Required Flags - determine which claim line fields are required for lines containing
this revenue code on claims having the specified LOB/TOB. The claim line "Units",
"Rate", "HCPCS", and "Remarks" fields are represented by these flags. (Default =
Not Required)
When checked, the corresponding field is required for claim lines containing this
revenue code on claims having the specified LOB/TOB combination.
When unchecked, the corresponding field is not required for claim lines
containing this revenue code on claims having the specified LOB/TOB
combination.
Is Accommodation? - determines whether or not the revenue code represents an
"accommodation" for claims having the specified LOB/TOB combination. (Default =
Not An Accommodation)
When checked, the revenue code represents an "accommodation" for claims
having the specified LOB/TOB combination.
When unchecked, the revenue code does not represent an "accommodation" for
claims having the specified LOB/TOB combination.
Evaluating Revenue Code Assignments
During the claim edit validation process, revenue code assignment records are considered in
order from "most-specific" to "least-specific" (i.e., from bottom-to-top as they appear on the
Revenue Code Assignments form). As soon as an acceptable match is found, the search ends
and edit validation decisions are made based on control settings for the matching assignment
record (if any). For example, if the following 3 detail assignment records exist for revenue code
"0022":
LOB = << ALL >> ; TOB = << ALL >>
LOB = << ALL >> ; TOB = 11
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LOB = MCA ; TOB = 11
Case 1: Medicare claim (LOB = "MCA") with a TOB = "112" - claim lines with a revenue code
of "0022" would use control settings from the third record above during edit validation, since
both the LOB and TOB are an exact match.
Case 2: Commercial claim (LOB = "COM") with a TOB = "112" - claim lines with a revenue
code of "0022" would use control settings from the second record above during edit validation,
since the TOB matches and the LOB of "<< ALL >>" matches any claim LOB. The third record
was rejected because of the LOB mismatch ("MCA" versus "COM").
Case 3: Medicare claim (LOB = "MCA") with a TOB = "122" - claim lines with a revenue code
of "0022" would use control settings from the first record above during edit validation, since the
TOB of "<< ALL >>" matches any claim TOB, and the LOB of "<< ALL >>" matches any claim
LOB. The third and second records were rejected because of the TOB mismatch ("12" versus
"11").
In our example, the first record was a "catch-all" record since it matched all LOBs and TOBs. If
that assignment record were not present, then Case 3 above (MCA/122) would not have
matched any of the detail assignment records. When this occurs, the revenue code is
considered valid and the remaining control setting flags will assume their default values during
edit validation processing.
Note: Revenue Code Assignment records that include a specific TOB value take
precedence over records with the special "IP" (inpatient) and "OP" (outpatient) TOB
values. This evaluation sequence makes it possible to define an inpatient/outpatient
group assignment that is valid for most TOBs in the group. Separate assignment
records with specific TOB values can be created as needed to handle exceptions to the
group rule.
By understanding this matching process, it is possible to build a revenue code assignment
details set that can be as open or as specific as required.
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Place of Service (POS) File Maintenance
The Place of Service (POS) Codes form provides an interface to maintain the Place of Service
(POS) codes and assignments. POS codes apply exclusively to Professional claims. The POS
codes are pre-loaded and should not require frequent additions or modifications. The Place of
Service (POS) form includes two tabs:
Descriptions - displays a list of Place of Service (POS) codes and their descriptions.
Maintenance operations available are:
To add a POS code, click the "New" button and enter the new POS code
information. Enter the effective date range using a 4-digit year format.
To view or modify an existing POS record, select the desired record and click the
"View/Update" button (or double-click the desired record).
To delete a POS record, select the desired record from the list, click the "Delete"
button, and confirm the deletion.
Assignments - defines the list of valid Place of Service (POS) codes for each line of
business (LOB). These assignments will also determine which POS codes will be
included in the POS lookup list presented during claim entry. The POS assignment
maintenance options include:
Select LOB - filters the assignment list to include only assignments for a specific line
of business. When a specific LOB is selected, it will be used as the default LOB for
new POS code assignments.
To add a new POS code assignment record, click the "New" button on the
Assignments tab. Select the default LOB and POS code from the drop-down lists.
To delete a POS code assignment record, select the desired record, click the
"Delete" button, and confirm the deletion.
Effective Date Range
The Effective Date Range dates are compared to the associated claim line's service date
range during the claim edit validation process. If the effective date range for a Place of Service
(POS) code falls outside the line's service date range, an edit validation error will be reported.
If the effective date range is left blank, the POS code is valid for all dates of service. If the start
date is completed but the end date is left blank, the POS code is valid for all dates of service
from (and including) the start date forward. If the start date is left blank but the end date is
completed, the POS code is valid for all dates of service up to (and including) the end date.
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Facility File Maintenance
The Facility Setup form provides an interface to maintain the optional Facility reference file.
The Facility file applies exclusively to Professional claims. The user may enter Facility records
for each frequently referenced facility if desired. The Facility reference file is available as a
lookup list from the Extended Patient/General tab on the "Professional Claim Form".
Maintenance operations available include:
To add a Facility, click the "New" button and enter the new facility information.
To view or modify an existing Facility record, select the desired record, click the
"View/Update" button (or double-click the desired record).
To delete a Facility record, select the desired record, click the "Delete" button, and
confirm the deletion.
Tip: A convenient "Sort By" feature quickly sorts the Facility list by "Facility Name" or
"Facility ID".
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Charges Master File Maintenance
The Charges Master form provides an interface to maintain the Charges Master reference file.
Charges Master codes apply exclusively to Professional claims. If you choose to use this
optional reference file, it should be setup to include only those procedure codes that are to be
used by the billing office (rather than the entire HCPCS code universe). Using a Charges
Master file will reduce the size of the HCPCS code lookup lists during claim entry, thus
promoting accuracy and enhancing productivity. In addition, a dollar amount may be assigned
to each Charges Master entry. This value is automatically brought forward to the claim line
item "Charges" field when a valid Charges Master code is entered (or looked up) during claim
entry. Maintenance operations available include:
To add a new Charges Master code, click the "New" button and optionally select a
specific line of business (LOB) from the dropdown list if the charge is specific to claims
for a particular LOB. Enter an optional "Payer ID" value if the charge is specific to claims
billed to a particular payer. See the discussion of LOB/Payer-specific Charges Master
records below for more information. Enter a valid HCPCS Code. Alternatively, the Payer
ID and HCPCS Code values can be selected from a lookup list by pressing the "F2" key
or right-clicking the mouse while positioned on the respective control. Enter the desired
"Charges" value and click the "OK" button to save the new record.
To view or modify an existing Charges Master record, select the desired record and click
the "View/Update" button (or double-click the desired record). Only the description and
charge amount fields may be modified.
To delete a Charges Master record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
LOB/Payer-Specific Charges Master Records
The Charges Master reference file allows you to create multiple records for the same HCPCS
code, each applicable to a specific line of business (LOB) and, optionally, to a specific payer
within that line of business. This feature is useful if your "standard" charge for a procedure
varies depending on the claim’s LOB (or depending on the payer within that LOB). In addition,
a default record for each HCPCS code may be added using the special "<< All >>" pseudoLOB option. During Professional claim entry, the HCPCS code lookup lists will include only the
most specific record(s) available for each HCPCS code. For example, suppose three Charges
Master records have been added for HCPCS code "00100" as follows:
Code = 00100 ; LOB = << ALL >> ; Payer ID = (left blank)
Code = 00100 ; LOB = COM ; Payer ID = (left blank)
Code = 00100 ; LOB = COM ; Payer ID = 12345
The HCPCS code lookup list presented during entry of a commercial claim (LOB = "COM")
would include only the LOB-specific "COM" records for code "00100" (i.e., the last 2 records).
The same lookup operation performed during entry of claims for all other LOBs would include
only the non-LOB-specific "<< All >>" record for code "00100".
When an HCPCS code is entered manually in the Professional Claim Form (as opposed to
performing a lookup operation), the program will attempt to locate the most specific record
match based on the claim's line of business and payer(s). For example, if the HCPCS code
"00100" is entered manually on a commercial claim (LOB = "COM") for Payer ID = "12345",
the program will automatically use the charge amount associated with the matching payerspecific record (i.e., the third record above). If the commercial claim is being billed to any other
payer, however, the program will instead use the charge amount from the non-payer-specific
record (i.e., the second record above). Finally, if the HCPCS code "00100" is entered manually
on a non-commercial claim, the program will use the charge amount from the default (i.e., first)
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Charges Master record. If the appropriate Charges Master record cannot be automatically
determined with complete certainty, then the user will be prompted to select the desired
record.
If your installation does not require LOB-specific and/or LOB/Payer-specific charge amounts,
then simply setup all Charges Master records using the "<< All >>" pseudo line of business,
and leave the "Payer ID" field empty.
Note: By default, procedure code lookups performed during Professional claim entry
access the master HCPCS reference file. To use the Charges Master file instead, you
must first create records in this reference file for all desired procedure codes (along
with their standard "Charges" amounts). Second, enable lookups to this file by checking
the "Use Charges Master reference file for Professional procedure code lookups"
option in the PC-ACE Pro32 "General Preferences" tab.
Tip: The Charges Master form provides several List Filter Options that can be helpful in
locating specific codes. Refer to the "Reference File Maintenance Form" topic for more
discussion of these common filter options.
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Common Reference File Procedures
Provider Specialty File Maintenance
The Provider Specialties form provides an interface to maintain the Provider Specialty codes.
Provider Specialty codes apply exclusively to Professional providers. The Provider Specialty is
a required field on the Professional Provider Information form. These codes are pre-loaded
and should require minimal maintenance. Maintenance operations available include:
To add a Provider Specialty code, click the "New" button and enter the new code
information.
To view or modify an existing Provider Specialty record, select the desired record and
click the "View/Update" button (or double-click the desired record).
To delete a Provider Specialty record, select the desired record from the list, click the
"Delete" button, and confirm the deletion.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Adding and maintaining providers (Professional)" topic for a discussion of
Professional provider maintenance.
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Provider Taxonomy Codes File Maintenance
The Provider Taxonomy Codes form provides an interface to maintain the Provider Taxonomy
codes. Provider Taxonomy codes may be required for submission of EMC files in ANSI-837
format. The Provider Taxonomy code is a field on the Institutional and Professional Provider
Information forms. These codes are pre-loaded and should require minimal maintenance.
Maintenance operations available include:
To add a Provider Taxonomy code, click the "New" button and enter the new code
information.
To view or modify an existing Provider Taxonomy code record, select the desired record
and click the "View/Update" button (or double-click the desired record).
To delete a Provider Taxonomy code record, select the desired record from the list, click
the "Delete" button, and confirm the deletion.
Tip: The Provider Taxonomy Codes form provides several List Filter Options that can be
helpful in locating specific codes. Refer to the "Reference File Maintenance Form" topic
for more discussion of these common filter options.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Adding and maintaining providers (Institutional)" topic for a discussion of
Institutional provider maintenance.
Refer to the "Adding and maintaining providers (Professional)" topic for a discussion of
Professional provider maintenance.
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Claim Adjustment Reason Codes File Maintenance
The Claim Adjustment Reason Codes form provides an interface to maintain the Claim
Adjustment Reason codes. These reason codes are used on Coordination of Benefits (COB)
claims to report prior payer information. They are pre-loaded and should require minimal
maintenance. Maintenance operations available include:
To add a Claim Adjustment Reason code, click the "New" button and enter the new code
information.
To view or modify an existing Claim Adjustment Reason code record, select the desired
record and click the "View/Update" button (or double-click the desired record).
To delete a Claim Adjustment Reason code record, select the desired record from the
list, click the "Delete" button, and confirm the deletion.
Tip: The Claim Adjustment Reason Codes form provides several List Filter Options that
can be helpful in locating specific codes. Refer to the "Reference File Maintenance Form"
topic for more discussion of these common filter options.
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Remittance Remark Codes File Maintenance
The Remittance Remark Codes form provides an interface to maintain the Remittance Remark
codes. These remark codes are used on Coordination of Benefits (COB) claims to report prior
payer information. They are pre-loaded and should require minimal maintenance. Maintenance
operations available include:
To add a Remittance Remark Reason code, click the "New" button and enter the new
code information.
To view or modify an existing Remittance Remark code record, select the desired record
and click the "View/Update" button (or double-click the desired record).
To delete a Remittance Remark code record, select the desired record from the list, click
the "Delete" button, and confirm the deletion.
Tip: When the Remittance Remark Code description is too long to be displayed in the
list, the description is truncated and the phrase "(right-click for full text)" is displayed. To
view the complete code description, simply right-click on the desired record. The full
description text will be presented in a read-only window.
Tip: The Remittance Remark Codes form provides several List Filter Options that can be
helpful in locating specific codes. Refer to the "Reference File Maintenance Form" topic
for more discussion of these common filter options.
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Miscellaneous Functions
Eligibility Request Service Type Codes File Maintenance
The Eligibility Request Service Type Codes form provides an interface to maintain the
Eligibility Request Service Type codes. These service type codes are used on ANSI-270
eligibility/benefit requests to indicate the service for which benefit information is being
requested. They are pre-loaded and should require minimal maintenance. Maintenance
operations available include:
To add an Eligibility Request Service Type code, click the "New" button and enter the
new code information.
To view or modify an existing Eligibility Request Service Type code record, select the
desired record and click the "View/Update" button (or double-click the desired record).
To delete an Eligibility Request Service Type code record, select the desired record from
the list, click the "Delete" button, and confirm the deletion.
Tip: The Eligibility Request Service Type Codes form provides several List Filter Options
that can be helpful in locating specific codes. Refer to the "Reference File Maintenance
Form" topic for more discussion of these common filter options.
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Claim Status Response Codes File Maintenance
The Claim Status Response Codes form provides an interface to maintain the Claim Status
Response codes. Three groups of response codes are defined: category codes, status
codes, and entity codes. Select the desired "List includes:" radio button to display the
desired group. Claim Status Response codes are reported on ANSI-277 claim status response
transactions. They are pre-loaded and should require minimal maintenance. Maintenance
operations available include:
To add a Claim Status Response code, select the desired "List includes:" group, click
the "New" button, and enter the new code information.
To view or modify an existing Claim Status Response code record, select the desired
"List includes:" group, select the desired record in this group, and click the
"View/Update" button (or double-click the desired record).
To delete a Claim Status Response record, select the desired "List includes:" group,
select the desired record from the list, click the "Delete" button, and confirm the deletion.
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Miscellaneous Functions
Miscellaneous Functions
Adding or modifying a system user
PC-ACE Pro32 requires that a valid login and optional password be entered by anyone
desiring access to the system. The system administrator must set up a "user" account for each
person that will use PC-ACE Pro32. The user account specifies the user's login/password
values and defines which activities the user has permission to perform. To add a new user or
modify an existing user, select the main "Security" menu from the PC-ACE Pro32 Main
Toolbar and choose the "Add/Update User" item. Only users with "User Add/Modify"
privileges can perform these maintenance functions, which include:
To add a new user, click the "New" button on the Security List form and assign the user
a User ID, Password and Name. Assign permissions to this user and save the new user
record.
To modify an existing user, select the desired user from the Security List form and click
the "View/Update" button (or double-click the user record). Modify the Password, User
Name, and User Permissions fields as desired. When all changes have been made,
save the modified user record.
Tip: Check the checkbox next to the permission to allow access to the activity. Click the
"Check All" and "Clear All" buttons to quickly check or un-check all user permission
checkboxes.
Attention: If changes are made to a user profile, the changes will not go into effect until
the next time that user logs into system. Select the "Logout Current User" item,
available from the main "Security" menu to manually log out without exiting the system.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Security & User Maintenance" topic for more information about the PC-ACE
Pro32 security implementation and the User Security Update form.
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Scheduling unattended claim activities
Claim import, processing, and transmission activities may be scheduled for unattended
operation if desired. This feature can be used to enhance productivity by automatically
performing time-consuming tasks that night otherwise require an operator to be present. Tasks
may be scheduled for either one-time deferred execution or daily recurring execution at a
specified time by clicking the "Claim Activity Scheduling" button on the PC-ACE Pro32 Main
Toolbar.
Note: This claim activity scheduling feature may not be available in all installations. You
will be notified when you attempt to enter the scheduling module if the distributor has
disabled this feature.
The Claim Activity Scheduling form consists of 3 tabs each for Institutional and Professional
claim activity scheduling. If you are licensed for only Institutional or Professional claim activities
(but not both), then you will see only a single set of 3 tabs. A common set of 3 scheduling
options are presented on each of the tabs:
No claim … scheduling - when selected, no claim import, processing, or transmission
activity is currently scheduled.
Manually initiate deferred claim … (one-time execution) - when selected, the scheduler
will initiate a one-time claim import, processing, or transmission activity at the next
occurrence of the specified start time.
Automatically initiate deferred claim … each day - when selected, the scheduler will
initiate a claim import, processing, or transmission activity daily at the specified start time.
In addition to selecting the desired scheduling option, each scheduled activity type requires
some specific configuration.
Claim Import Scheduling - To schedule an unattended claim import operation, click the
desired Institutional or Professional "Claim Import" tab, select either the one-time or
daily scheduling option, and enter the desired "Start Time". Specify the following importspecific scheduling options:
Import claims only - instructs the scheduler to perform the claim import operation
only. See the "Import and process claims" option description below for an alternate
approach.
Import and process claims - instructs the scheduler to perform the claim import
operation followed immediately by a claim processing operation on all unprocessed
claims in the system. This option provides a smooth transition from the claim import
operation to the claim processing operation, and relieves the user from the need to
schedule the claim processing run separately.
Note: Selecting the "Import and process claims" option will disable the 3
scheduling options on the "Claim Process" tab, since claim processing is now
"chained" to the claim import operation.
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Import Map/Print File Selection - select (check) one or more PrintLink map files to
be imported at the scheduled time. Each valid PrintLink map file present in the predefined claim import directory will be represented in this selection list.
Miscellaneous Functions
Note: This selection list will be visible only if PC-ACE Pro32 is configured to
use the standard PrintLink claim import method. Refer to the "Claim Import
Preferences" topic for more information on claim import configuration.
Once all scheduling options are completed, click the "Initiate Deferred Claim Import"
button to complete the scheduling task. If all scheduling tasks have been completed,
click the "OK" button to close the form and return to the PC-ACE Pro32 Main Toolbar.
Claim Process Scheduling - To schedule an unattended claim processing operation,
click the desired Institutional or Professional "Claim Process" tab, select either the onetime or daily scheduling option, and enter the desired "Start Time". Specify the following
process-specific scheduling options:
Include claims with errors - When checked, instructs the scheduler to process all
claims that have been previously saved with errors (fatal or non-fatal) in addition to
all unprocessed claims. When left unchecked, only unprocessed claims will be
included in the processing run.
Process LOB Selection - select (check) one or more lines of business (LOB) to be
considered during the claim processing operation. Only claims with the specified
LOBs will be processed. Select the special "<< PROCESS ALL LOBS >>" item to
process claims for all LOBs.
Once all scheduling options are completed, click the "Initiate Deferred Claim
Processing" button to complete the scheduling task. If all scheduling tasks have been
completed, click the "OK" button to close the form and return to the PC-ACE Pro32 Main
Toolbar.
Note: If the "Import and process claims" option is checked on the "Claim Import"
scheduling tab, then the scheduler will initiate claim processing immediately upon
completion of the claim import operation. The claim process schedule will be
reported as "controlled by claim import settings."
Claim Transmission Scheduling - To schedule an unattended claim transmission (or
other data communication) operation, click the desired Institutional or Professional
"Claim Transmit" tab, select either the one-time or daily scheduling option, and enter
the desired "Start Time". Specify the following transmit-specific scheduling options:
Data Comm Claim Transmission Function - specifies the data communication
function to be launched at the specified start time. Select the desired function from
the drop-down list provided.
Note: The scheduler is responsible only for launching the program or batch file
associated with the selected claim transmission function. It does not attempt to
monitor the progress or completion status of this data communications operation. If
no items are available in the drop-down list, then no data communications
programs have been configured for launch from PC-ACE Pro32. Refer to the "Data
Communication Preferences" topic for more information on configuring Data
Communications program access.
Once all scheduling options are completed, click the "Initiate Deferred Claim
Transmission" button to complete the scheduling task. If all scheduling tasks have been
completed, click the "OK" button to close the form and return to the PC-ACE Pro32 Main
Toolbar.
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Tip: Don't forget to click the "Initiate Deferred Claim …" button after setting up for a
scheduled claim activity. You will see a notification message in red at the bottom of the
tab when the activity is properly scheduled.
Scheduled Activity Notification
Approximately 5 minutes prior to the start time of a scheduled claim activity, the Scheduled
Activity Notification form will be automatically displayed on the client workstation. This
notification form describes the scheduled activity type and displays an approximate countdown
timer. To insure success of the scheduled claim activity, the user should refrain from using the
system until the scheduled activity has completed. When you see this notification form, click
the "OK" button and return to the PC-ACE Pro32 Main Toolbar. Once the scheduled activity is
initiated, the status bar along the lower edge of the PC-ACE Pro32 Main Toolbar will display
messages describing the progress of the scheduled activity. The status bar will be blanked
when the scheduled activity completes. You may then review the claim activity log to see the
outcome of the scheduled claim activity, if desired. Once the scheduled activity has completed,
you may resume normal use of PC-ACE Pro32.
Attention: PC-ACE Pro32 must be running for scheduled activities to execute. If
desired, minimize the PC-ACE Pro32 Main Toolbar on your desktop after scheduling
claim activities.
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Miscellaneous Functions
Launching the ANSI-835 Electronic Remittance Module
The optional ANSI-835 Electronic Remittance modules provide tools for processing the
electronic remittance files returned from your claims processor. Electronic remittance data can
be viewed, printed and/or exported using these tools. Exported remittance data can, for
example, be used to automatically post payments to an upstream claims management system.
Separate ANSI-835 modules exist for use with Institutional and Professional claims.
The ANSI-835 Electronic Remittance modules expect to find remittance files in the
following directory:
Place Institutional remittance files in the server's "winpcace\etraub92\ansi835"
directory.
Place Professional remittance files in the server's "winpcace\etra1500\ansi835"
directory.
To launch an ANSI-835 program, click the "ANSI-835 Functions" button on the "PCACE Pro32 Main Toolbar". Click the desired button to launch either the Institutional
(ETRA) or Professional (ETRA1500) electronic remittance program.
Note: The second-level launch buttons may not be presented if only a single ANSI-835
Electronic Remittance module is configured for your installation. Refer to the separate
ANSI-835 Electronic Remittance (ETRA) module manuals for information about the
capabilities and operation of these programs.
Attention: The ANSI-835 Electronic Remittance modules are not available on all
systems. If either or both of these launch buttons are disabled, then the corresponding
ANSI-835 module is not available.
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Performing system backups/restores
PC-ACE Pro32 provides complete database backup, validation, and restore facilities to protect
your valuable system data. All claims, reference files, and system configuration settings can be
backed up to either removable media (diskettes, writeable CDROM) or a standard Windows
directory (local or remote). In the event a catastrophic system failure results in the loss or
compromise of PC-ACE Pro32 database files, a complete database restore operation can be
performed from the most recent backup.
Attention: These backup facilities are designed to protect just the PC-ACE Pro32
databases and configuration information. The program executable files and other
support files are not included in the backup archive. It is strongly recommended that
you supplement these backups with a comprehensive backup schedule for your server
and client systems. In the event a full restore is required, you would first restore from a
full-system backup to rebuild the system's directory hierarchy and restore all program
and support files. The most recent PC-ACE Pro32 backup could then be restored to
recover your databases and configuration settings.
You will be prompted to perform a backup each time you exit the PC-ACE Pro32 program
(unless your distributor has disabled this prompt feature). You may also perform a backup from
the "Backup/Restore" tab of the System Utilities form. This form can be accessed by clicking
the "System Utilities" button from the PC-ACE Pro32 Main Toolbar. The following sections
describe the backup, validate, and restore options and operation:
Backup - performs a backup of the PC-ACE Pro32 database files and configuration
settings. All files to be included are compressed into a single archive and written to the
specified destination drive or directory. The following controls and options apply to the
backup operation:
Destination Drive or Folder - specifies the drive or Windows folder (directory) to
which the backup archive file will be written. This path may point to a removable
media device (diskettes, writeable CDROM) or to a standard Windows directory on a
hard disk drive (local or remote). Disk "spanning" is supported for backups to
diskette. The user will be prompted to insert blank diskettes as needed.
Tip: If you are unable to perform the backup directly to your writeable CDROM
drive for any reason, simply set the destination to a hard drive folder and then
copy the resulting PCACEPBK.ZIP file to the CD using whatever technique you
normally use for saving files to the CDROM drive..
Include infrequently changed database files - specifies whether or not to include
certain infrequently changed database files in the backup. The optional files include
only reference file databases that are generally static for long periods of time.
Examples include the HCPCS Codes and Edit Validation database files. The backup
archive will be somewhat smaller if these optional files are omitted.
Tip: To ensure minimal problems in the event a database restore is required, we
recommend leaving this option checked for all backups.
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Options Button: Include archived claim transmission (EMC) files in backup specifies whether or not to include all archived EMC files in the backup.
Options Button: Include claim archive database files in backup - specifies
whether or not to include the claim archive database files in the backup. Refer to the
"Archiving and unarchiving claims" topic for more information on the PC-ACE Pro32
claim archive feature.
Miscellaneous Functions
Options Button: Include archived ANSI response files in backup - specifies
whether or not to include all archived ANSI-271, ANSI-277, ANSI-277CA, and ANSI997/999 files in the backup.
Options Button: Include archived ANSI-835 remittance files in backup specifies whether or not to include the ANSI-835 remittance file archive and related
configuration files in the backup. This option will be disabled if the ANSI-835
Electronic Remittance Processors are not available on your installation.
Options Button: Include archived Report Manager response report files in
backup - specifies whether or not to include the response reports archived by the
optional PC-ACE Pro32 Report Manager program in the backup. This option will be
disabled if the Report Manager is not available on your installation.
Once the desired destination and options have been specified, click the "Start Backup"
button to proceed. You will be notified upon successful backup completion.
Note: Exclusive system access is required to perform backups in PC-ACE Pro32. If
this program is in use on another client workstation, you will be notified when the
"Start Backup" button is clicked. You can either instruct the other users to exit PCACE Pro32 and then continue the backup, or simply cancel the backup request.
Validate - validates an existing backup file. The backup archive's integrity is confirmed,
and the archive details (date of backup, etc) are presented to the user. No data will be
restored during the validation process, so it is always "safe" (and advisable) to validate an
archive before attempting a subsequent restore operation. The following controls and
options apply to the validate operation:
Source Drive or Folder - specifies the drive or Windows folder (directory) from
which the backup archive file will be read. This path may point to a removable media
device (diskettes, writeable CDROM) or to a standard Windows directory on a hard
disk drive (local or remote). Disk "spanning" is supported for backup archives on
diskette. The user will be prompted to insert specific diskettes from the backup
archive as needed.
Tip: When validating backup archives that span multiple diskettes, insert the last
diskette in the set first. The system will prompt for the first and subsequent
diskettes as the validation proceeds.
Once the desired source drive/folder path has been specified, click the "Start Validate"
button to proceed. You will be presented with details of the validated backup archive on
completion.
Restore - restores the PC-ACE Pro32 database files and configuration settings (optional)
from an existing backup file. The "Restore" tab will be visible only to users with the
appropriate permissions. The following controls and options apply to the restore operation:
Source Drive or Folder - specifies the drive or Windows folder (directory) from
which the backup archive file will be read. This path may point to a removable media
device (diskettes, writeable CDROM) or to a standard Windows directory on a hard
disk drive (local or remote). Disk "spanning" is supported for backup archives on
diskette. The user will be prompted to insert specific diskettes from the backup
archive as needed.
Tip: When restoring backup archives that span multiple diskettes, insert the last
diskette in the set first. The system will prompt for the first and subsequent
diskettes as the restoration proceeds.
Restore system and user configuration settings - specifies whether or not to
restore the system and user configuration settings that were included in the backup
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archive. These settings define system/user preference settings, for example. Unless
otherwise instructed by a technical support specialist, this option should always be
checked.
Once the desired source drive/folder path and option settings have been specified, click
the "Start Restore" button to proceed.
Attention: The restore operation will overwrite your current database files
with older data from the specified backup. You should perform this operation
only under the supervision of authorized technical support personnel.
You will be notified when the restore operation completes. PC-ACE Pro32 will terminate
automatically following a restore operation. The restored database files and configuration
settings will be available the next time the program is executed.
Note: Exclusive system access is required to perform a restore operation in PCACE Pro32. If this program is in use on another client workstation, you will be
notified when the "Start Restore" button is clicked. You can either instruct the
other users to exit PC-ACE Pro32 and then continue the restore operation, or
simply cancel the restore request.
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Miscellaneous Functions
Packing and reindexing the databases
PC-ACE Pro32 uses proven database technology that is, for the most part, self-maintaining.
Database files (or "tables") contain the data records that define a claim, patient, provider, etc.
Most tables are equipped with "indexes" that organize the records in the table for optimal
access. As records are added to, modified, or deleted from a database table, the PC-ACE
Pro32 database engine performs all necessary housekeeping. For example, all indexes are
maintained to reflect the current set of records after one or more records has been added,
modified, or deleted.
Having said this, there are certain situations when the system administrator may be required to
perform manual database maintenance operations. The most common scenarios include:
Frequently updated tables (claim tables, for example) may require periodic maintenance
to keep their size at a minimum and their performance optimized.
Indexes may become out-of-date due to an abnormal system or network problem that
interferes with the PC-ACE Pro32 database engine's self-maintenance tasks.
In these scenarios, and others that occur less frequently, database tables(s) may require
manual "packing" and/or "reindexing".
Database Packing - As records are deleted from PC-ACE Pro32 database tables, the
file/disk space consumed by these deleted records is not automatically recovered. Over
time, this unrecovered space can result in a table that consumes more disk space that it
really needs. In addition, the unnecessarily large table can have an impact on database
performance. When a database table is "packed", this unrecovered space is eliminated,
resulting in a table that is as small as possible, and optimum performance is restored. As
an example of when packing would be recommended, consider the claim archiving
process. One of the primary motivations behind claim archiving is to keep the current
claims database tables as small and as fast as possible by moving older claims to "offline" storage. However, once a group of claims have been archived, the current claims
database tables must be packed in order to fully realize the size and performance
benefits. Database packing is typically the responsibility of your system administrator.
Database Reindexing - Database "indexes" facilitate optimized access to the information
in a database table. As data in the table changes, these indexes must be updated to
accurately reflect the current table contents. Indexes are normally maintained
automatically by the PC-ACE Pro32 database engine. If an index gets "out-of-date" as the
result of some unexpected system or network malfunction, it may become necessary to
manually reindex the associated table. Database reindexing is typically the responsibility
of your system administrator.
File maintenance operations like packing and reindexing require appropriate user permission.
You will be notified if your user is not authorized to perform these functions. In addition, these
functions require exclusive system access.
Tip: To greatly reduce the time required to perform claim archiving activities on
networked installations, it is strongly recommended that such activities be initiated
from the server's console.
To pack or reindex a table(s):
1) Click the "System Utilities" button on the PC-ACE Pro32 Main Toolbar to display the
System Utilities form. Select the "File Maintenance" tab.
2) Select one or more tables from the "Database Files" list.
Tip: Select multiple database files by holding down the "CTRL" key while clicking the
desired list items. Click the "Select All" button to select all database files.
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3) Click the "Pack" button or "Reindex" button to perform the desired operation on all selected
database files.
Certain database files (tables) should normally be worked with as a group. For example, there
are 5 separate database files that make up the Institutional claims database. The "Select
Group" drop-down list provides a convenient means of selecting all associated files in one of
several commonly used groups. Use this selection technique instead of selecting database
files individually from the list.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Archiving and unarchiving claims" topic for information on the PC-ACE Pro32
claim archiving feature and its potential to enhance system performance.
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Miscellaneous Functions
Sending support mail to your distributor
Technical support e-mail can be initiated directly from the PC-ACE Pro32 system. Click the
"Send E-Mail" button on the PC-ACE Pro32 Main Toolbar to command your default e-mail
program to open a new message addressed to your distributor.
Note: This feature may not be available on some systems. If the support mail feature is
disabled, the "Send E-Mail" button will not be present on the PC-ACE Pro32 Main
Toolbar. If the button is available, but does not open an e-mail message window, it is
likely that your system does not have its default mailer properly configured.
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Troubleshooting
Reviewing the claim activity logs
The Claim Activity Log files provide details of all claim import, process, prepare, and
transmission activities. The logs also record any abnormal activities that may occur in the
course of operation. Separate log files are maintained for Institutional and Professional claim
activities. The logs can be useful when researching past claim processing activity or reviewing
the outcome of scheduled claim activities.
To view a claim activity log file, select the "View" and "Claim Activity Log" items from
the Institutional or Professional Claims Menu form's main menu. The applicable log file
will be opened in the Windows "Wordpad" program. Activities are logged chronologically,
with the most recent entries at the end of the file.
Tip: Be sure and close Wordpad when you are finished reviewing the log.
To purge a claim activity log file, select the "Maintain" and "Purge Claim Activity Log"
items from the Institutional or Professional Claims Menu form's main menu. This action
simply deletes the appropriate Claim Activity Log file. The next claim import, process,
prepare, or transmission will start a new log file. Since the number of days for which
entries are maintained in this log can be set in the PC-ACE Pro32 preferences, this
function will rarely be used.
Related Topics:
The following hyperlinks provide additional information related to this topic:
Refer to the "Miscellaneous Preferences" topic for more information on the claim activity
log auto-purge feature.
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PC-ACE Pro32 User's Manual
Recovering from an interrupted claim prepare run
Claim prepare operations in PC-ACE Pro32 require exclusive system access. No other users
may be running the program while claims are being prepared. This exclusivity restriction is
imposed intentionally in order to help guarantee the integrity of the prepare operation. Even
with this protection, however, it is still possible that an abnormal system and/or network failure
could result in an interruption of the prepare operation prior to successful completion. If this
were to happen, it becomes important to recover from the interruption in such a way that
maintains the integrity of the claims being prepared.
When the user clicks the "Prepare" button and confirms the request, PC-ACE Pro32 saves
detailed information about the claims to be prepared before the actual prepare work begins. If
the prepare process is subsequently interrupted, this saved information can be accessed to
restore all affected claims to their state prior to initiation of the prepare operation. The next
time PC-ACE Pro32 is executed following the system interruption, the program will
automatically recognize that a prepare operation was in progress when the interruption
occurred.
Claim Prepare Recovery Options
The distributor determines the level of user interaction required to recover from an interrupted
claim prepare run. There are two possible scenarios:
Silent recovery - No user interaction is required. PC-ACE Pro32 automatically detects
that a prepare run was interrupted, restores the affected claims to their pre-prepare state,
and simply notifies the user that this recovery process has taken place.
Verbose recovery - Upon detecting that a prepare operation has been interrupted, the
user is presented with the Claim Prepare Recovery Options form. This form notifies the
user that a prepare run was interrupted and provides specific details of the prepare
operation in progress including time, date, EMC filename, EMC file format, and the
prepare filter and option settings specified by the user when the prepare run was initiated.
In the "verbose" recovery mode, the user has 3 options (represented by buttons on the
recovery options form):
Perform Recovery - Performs the prepare recovery process without further
prompting. All affected claims will be restored to their pre-prepare state. This is the
recommended course of action, unless a technical support specialist has instructed
you otherwise.
Skip Recovery - Skips the recovery process and leaves the affected claims in an
undetermined state. You will be warned that some affected claims may be flagged
as "transmitted" and may need to be reactivated. Skipping the recovery process
should only be done under the instruction of a technical support specialist.
Cancel - Cancels the prepare recovery process and exits the program. Selecting
this option is the equivalent of saying "I have no idea what to do." Consult with your
system administrator or a technical support specialist for the suggested course of
action. The next time you execute PC-ACE Pro32, you will be presented with this
same prepare recovery options form.
If the first or second option is selected, the user will be required to log in using the same
User ID and password that was in effect when the prepare interruption occurred. Upon
successful login, the prepare recovery process will either be performed or skipped based
on the user's selection.
Once the recovery process has completed successfully, we suggest that you review the
affected claims using the Claims List form to insure that everything looks like it did before the
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Troubleshooting
prepare operation was initiated. You may then run the prepare operation again to prepare the
eligible claims.
Note: Claim prepare recovery requires exclusive system access. Since the prepare
operation itself requires exclusivity, this should never become an issue. In any event,
you will be notified if exclusive system access cannot be granted.
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PC-ACE Pro32 User's Manual
Index
acknowledgment files
117
actions on multiple claims at once
29
activity logs - viewing and purging
213
adding a new claim
101
Adding a new eligibility benefit request
138
adding a new Home Health Plan of Care
152
Adding a new Institutional Medical Attachment
157
Adding a new roster billing
149
Adding and maintaining patients
157
Adding and maintaining payers
160
Adding and maintaining providers (Institutional)
163
Adding and maintaining providers (Professional)
166
Adding or modifying a system user
201
Adobe Acrobat Reader path setup
98
alternate payer printing
128
Ambulance medical attachment
157
ANSI-267/277 claim status request/response history
126
ANSI-271 file review and maintenance
145
ANSI-277 file review and maintenance
123
ANSI-835 Electronic Remittance Module
205
ANSI-997 file review and maintenance
117
archiving claims
135
archiving transmission files
119
attachments - printing
128
audit tracking
83
automatic report printing
92
backing up your PC-ACE Pro32 databases
206
building the ANSI-270 eligibility benefit request file
142
building the ANSI-276 claim status request file
121
building the electronic claims file
112
Charges Master File Maintenance
192
Claim & Reference File Edit Validation
81
Claim Archive Feature
135
claim attachments - printing
128
Claim Form (Institutional)
35
Claim Form (Professional)
43
claim import in PC-ACE Pro32
104
claim import preferences
91
Claim List Form configuration
90
214
Index
Claim List Form Features
claim payments
29
131, 133
posting to Institutional claims
131
posting to Professional claims
133
claim printing preferences
92
claim status request/response history
126
claim status response and acknowledgment files
123
claims activity logs - viewing and purging
213
Claims Menu Form (Institutional or Professional)
Codes & Miscellaneous Reference Files Overview
28
169
Common Claim Activities101, 102, 104, 108, 109, 112, 115, 117, 119, 121, 123, 126, 128, 131, 133, 135, 138, 140, 14
Adding a new claim
101
Adding a new eligibility benefit request
138
Adding a new Home Health Plan of Care
152
Adding a new Institutional Medical Attachment
157
Adding a new roster billing
149
Archiving claims
135
Importing claims
104
Listing and modifying claims
102
Listing and modifying eligibility benefit requests
140
Listing and modifying Plans of Care
153
Listing and modifying roster billings
150
Posting claim payments (Institutional)
131
Posting claim payments (Professional)
133
Preparing claim status request files for transmission
121
Preparing claims for transmission
112
Preparing eligibility benefit request files for transmission
142
Printing claims
128
Printing Home Health Plans of Care
155
Processing claims automatically
109
Reactivating previously transmitted claims
119
Reversing the most recent claim import run
108
Transmitting electronic claim files
115
Unarchiving claims
135
Viewing ANSI-271 eligibility benefit response files
145
Viewing ANSI-277 claim status response and acknowledgment files
123
Viewing ANSI-997 transmission acknowledgment files
117
Viewing the eligibility benefit response for a specific request
147
Viewing the status request/response history for a claim
126
Common Reference File Procedures
157, 160, 163, 166, 169
Adding and maintaining patients
157
Adding and maintaining payers
160
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PC-ACE Pro32 User's Manual
Adding and maintaining providers (Institutional)
163
Adding and maintaining providers (Professional)
166
Maintaining Codes & Miscellaneous Reference Files
169
Condition/Occurrence/Span/Value Codes File Maintenance
185
Data Communications Control File
177
Data Communications File Maintenance
177
Data Communications preferences
97
edits explained
81
Eligibility Benefit Request Form
57
Eligibility Benefit Request List Form Features
51
eligibility benefit response files
145
EMC File claim import method
104
entering claim data (Institutional)
35
entering claim data (Professional)
43
entering claims
entering eligibility benefit request data
entering eligibility benefit requests
entering Plan of Care data
entering roster billing data (Professional)
101
57
138
73
68
entering roster billings
149
ESRD medical attachment
157
Facility File Maintenance
191
features list
field-level and file-level edits
Forms 485/486 (Home Health Plan of Care)
Getting started with PC-ACE Pro32
1
81
152
3
HCPCS Codes File Maintenance
179
HCPCS Modifiers File Maintenance
180
Help System - How To Use
3
Home Health Plan of Care Form
73
Home Health Plan of Care List Form Features
71
host phone and login setup
177
how to complete a claim
101
how to complete a Home health Plan of Care
152
how to complete a roster billing
149
how to complete an eligibility benefit request
138
how to complete an Institutional Medical Attachment
157
how to get started
3
How to use the on-line help system
3
ICD9 Codes File Maintenance
182
image overlay claim print method
128
Importing claims
104
216
Index
Installing PC-ACE Pro32
3
Institutional Claim Form
35
Institutional Eligibility Benefit Request Form
57
Institutional Medical Attachment List Form Features
76
Intermediate Format File claim import method
104
Introducing PC-ACE Pro32
1
launching data communications functions
115
Launching the ANSI-835 Electronic Remittance Module
205
Listing and modifying claims
102
Listing and modifying eligibility benefit requests
140
Listing and modifying Plans of Care
153
Listing and modifying roster billings
150
Logging in for the first time
3
main toolbar
27
maintaining reference files
76
maintaining various code reference files
169
Medical Attachments (Institutional)
157
Miscellaneous Functions
201, 202, 205, 206, 209, 211
Adding or modifying a system user
201
Launching the ANSI-835 Electronic Remittance Module
205
Packing and re-indexing the databases
209
Performing system backups/restores
206
Scheduling unattended claim activities
202
Sending support mail to your distributor
211
miscellaneous preferences
98
On-line help
3
optimizing your claims databases
209
Packing and re-indexing the databases
209
patient setup and maintenance
157
payer setup and maintenance
160
PC-ACE Pro32 Features
PC-ACE Pro32 Main Toolbar
PC-ACE Pro32 Setup Procedures
Setup of Institutional All-Payer Systems
1
27
7, 14, 20
14
Setup of Medicare Part A Systems
Setup of Professional Systems
7
20
performance suggestion - packing claims databases
209
Performing system backups/restores
206
permissions - user
83
Physician (UPIN) File Maintenance
183
Place of Service (POS) File Maintenance
189
Plan of Care (485/486) Form
73
217
PC-ACE Pro32 User's Manual
Posting claim payments (Institutional)
131
Posting claim payments (Professional)
133
preferences
85, 86, 90, 91, 92, 97, 98
Claim Import
91
Claim List Form
90
Data Communications
97
General
86
Miscellaneous
98
Overview
85
Printing
92
prepare run interruption recovery
214
Preparing claim status request files for transmission
121
Preparing claims for transmission
112
Preparing eligibility benefit request files for transmission
142
pre-printed form claim print method
128
printer selection (claims & reports)
92
printing claims
printing claim attachments
128
128
printing claims on pre-printed forms
128
printing claims on stock paper
128
Printing Home Health Plans of Care
Printing preferences
155
92
PrintLink claim import method
104
PrintLink matching strings
160
Processing claims automatically
109
Profesional Eligibility Benefit Request Form
57
Professional Claim Form
43
Professional Roster Billing Form
68
provider inheritance and association (Institutional)
163
provider inheritance and association (Professional)
166
provider setup and maintenance
163, 166
setting up Institutional providers
163
setting up Professional providers
166
Provider Specialty File Maintenance
194
Provider Taxonomy Codes File Maintenance
195
purging archived transmission files
98
purging claim activity logs
98
Reactivating previously transmitted claims
119
Recovering from an interrupted claim prepare run
214
Reference File Maintenance Form
76
reference file setup and maintenance171, 177, 179, 180, 182, 183, 184, 185, 186, 189, 190, 191, 192, 194, 195
Charges Master
218
192
Index
Condition/Occurrence/Span/Value Codes & Assignments
185
Data Communications
177
Facility
191
HCPCS Codes
179
HCPCS Modifiers & Assignments
180
ICD9 Codes
182
Physician (UPIN)
183
Place of Service (POS) Codes & Assignments
189
Provider Specialty
194
Provider Taxonomy Codes
195
Revenue Codes & Assignments
186
submitter
171
Type of Bill (TOB)
184
Type of Service (TOS) Codes & Assignments
190
Rehab 700/701 medical attachment
report printing preferences
157
92
restoring from a PC-ACE Pro32 backup
206
retransmitting an EMC file
119
Revenue Codes File Maintenance
186
Reversing the most recent claim import run
108
reviewing a claim's status request/response history
126
Reviewing the claim activity logs
213
Roster Billing Form (Professional)
68
Roster Billing List Form Features
66
saving and canceling claims (Institutional)
35
saving and canceling claims (Professional)
43
saving and canceling Plans of Care
73
saving and cancelling roster billings (Professional)
68
Scheduled Activity Notification
202
Scheduling unattended claim activities
202
Security & User Maintenance
Sending support mail to your distributor
Setup Procedures
Setup of Institutional All-Payer Systems
83
211
7, 14, 20
14
Setup of Medicare Part A Systems
Setup of Professional Systems
7
20
Submitter File Maintenance
171
submitter information
171
system requirements
3
system-level security setting
83
toolbar
27
Transmission acknowledgment files
117
219
PC-ACE Pro32 User's Manual
transmission file archive
119
Transmitting electronic claim files
115
Troubleshooting
213, 214
Recovering from an interrupted claim prepare run
214
Reviewing the claim activity logs
213
Type of Bill (TOB) File Maintenance
184
Type of Service (TOS) File Maintenance
190
unarchiving claims
135
user permissions
using claim archives
83
135
using the Eligibility Benefit Request form
57
using the Institutional claim form
35
using the Plan of Care form
73
using the Professional claim form
43
using the Professional roster billing form
68
validating a PC-ACE Pro32 backup
206
Viewing and maintaining claim status response and acknowledgment files
123
Viewing and maintaining eligibility benefit response files
145
Viewing and maintaining the claim status request/response history
126
Viewing and maintaining transmission acknowledgment files
117
Viewing the eligibility benefit response for a specific request
147
Welcome
what is an edit?
220
1
81
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